{
"description": null,
"_filename": "Questionnaire-qgen-ExplanationOfBenefit1.json",
"package_name": "hl7.fhir.r6.examples",
"date": "2025-04-01T12:16:37+11:00",
"publisher": "HL7 International / Financial Management",
"name": null,
"item": [ {
"item": [ {
"text": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"type": "display",
"linkId": "ExplanationOfBenefit-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.",
"type": "display",
"linkId": "ExplanationOfBenefit.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Logical id of this artifact",
"type": "string",
"linkId": "ExplanationOfBenefit.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"type": "display",
"linkId": "ExplanationOfBenefit.meta-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Metadata about the resource",
"type": "group",
"linkId": "ExplanationOfBenefit.meta",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.implicitRules-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "A set of rules under which this content was created",
"type": "string",
"linkId": "ExplanationOfBenefit.implicitRules.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.implicitRules",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "uri"
} ]
}, {
"item": [ {
"text": "The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"type": "display",
"linkId": "ExplanationOfBenefit.language-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "language",
"type": "coding",
"linkId": "ExplanationOfBenefit.language.value",
"repeats": false,
"required": false,
"answerConstraint": "optionsOrType"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.language",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
} ]
}, {
"item": [ {
"text": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.",
"type": "display",
"linkId": "ExplanationOfBenefit.text-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Text summary of the resource, for human interpretation",
"type": "group",
"linkId": "ExplanationOfBenefit.text",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels. Contained resources may be a resource type defined in the FHIR specification, or an [additional resource](resource.html#additional).",
"type": "display",
"linkId": "ExplanationOfBenefit.contained-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Contained, inline Resources",
"type": "group",
"linkId": "ExplanationOfBenefit.contained",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored",
"type": "group",
"linkId": "ExplanationOfBenefit.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A unique identifier assigned to this explanation of benefit.",
"type": "display",
"linkId": "ExplanationOfBenefit.identifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.identifier.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.identifier.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.identifier.value",
"repeats": false,
"required": false
} ],
"text": "Business Identifier for the resource",
"type": "group",
"linkId": "ExplanationOfBenefit.identifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The status of the resource instance. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"type": "display",
"linkId": "ExplanationOfBenefit.status-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "status",
"type": "coding",
"linkId": "ExplanationOfBenefit.status.value",
"repeats": false,
"required": false,
"answerConstraint": "optionsOrType"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.status",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
} ]
}, {
"item": [ {
"text": "The category of claim, e.g. oral, pharmacy, vision, institutional, professional. The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.",
"type": "display",
"linkId": "ExplanationOfBenefit.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.type.text",
"repeats": false,
"required": false
} ],
"text": "Category or discipline",
"type": "group",
"linkId": "ExplanationOfBenefit.type",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": "display",
"linkId": "ExplanationOfBenefit.subType-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.subType.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.subType.text",
"repeats": false,
"required": false
} ],
"text": "More granular claim type",
"type": "group",
"linkId": "ExplanationOfBenefit.subType",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.",
"type": "display",
"linkId": "ExplanationOfBenefit.use-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "use",
"type": "coding",
"linkId": "ExplanationOfBenefit.use.value",
"repeats": false,
"required": false,
"answerConstraint": "optionsOrType"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.use",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
} ]
}, {
"item": [ {
"text": "The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.",
"type": "display",
"linkId": "ExplanationOfBenefit.patient-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "The recipient of the products and services",
"type": "reference",
"linkId": "ExplanationOfBenefit.patient.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Patient"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.patient",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The period for which charges are being submitted. Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.",
"type": "display",
"linkId": "ExplanationOfBenefit.billablePeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.billablePeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.billablePeriod.end",
"repeats": false,
"required": false
} ],
"text": "Relevant time frame for the claim",
"type": "group",
"linkId": "ExplanationOfBenefit.billablePeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
}, {
"item": [ {
"text": "The date this resource was created.",
"type": "display",
"linkId": "ExplanationOfBenefit.created-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Response creation date",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.created.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.created",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "Individual who created the claim, predetermination or preauthorization.",
"type": "display",
"linkId": "ExplanationOfBenefit.enterer-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Author of the claim",
"type": "reference",
"linkId": "ExplanationOfBenefit.enterer.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Practitioner, PractitionerRole, Patient, RelatedPerson"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.enterer",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The party responsible for authorization, adjudication and reimbursement.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurer-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Party responsible for reimbursement",
"type": "reference",
"linkId": "ExplanationOfBenefit.insurer.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Organization"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.insurer",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The provider which is responsible for the claim, predetermination or preauthorization. Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.",
"type": "display",
"linkId": "ExplanationOfBenefit.provider-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Party responsible for the claim",
"type": "reference",
"linkId": "ExplanationOfBenefit.provider.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Practitioner, PractitionerRole, Organization"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.provider",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The provider-required urgency of processing the request. Typical values include: stat, normal deferred. If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.",
"type": "display",
"linkId": "ExplanationOfBenefit.priority-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.priority.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.priority.text",
"repeats": false,
"required": false
} ],
"text": "Desired processing urgency",
"type": "group",
"linkId": "ExplanationOfBenefit.priority",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code to indicate whether and for whom funds are to be reserved for future claims. This field is only used for preauthorizations.",
"type": "display",
"linkId": "ExplanationOfBenefit.fundsReserveRequested-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.fundsReserveRequested.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.fundsReserveRequested.text",
"repeats": false,
"required": false
} ],
"text": "For whom to reserve funds",
"type": "group",
"linkId": "ExplanationOfBenefit.fundsReserveRequested",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.",
"type": "display",
"linkId": "ExplanationOfBenefit.fundsReserve-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.fundsReserve.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.fundsReserve.text",
"repeats": false,
"required": false
} ],
"text": "Funds reserved status",
"type": "group",
"linkId": "ExplanationOfBenefit.fundsReserve",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "For example, for the original treatment and follow-up exams.",
"type": "display",
"linkId": "ExplanationOfBenefit.related-display"
}, {
"text": "Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.",
"type": "display",
"linkId": "ExplanationOfBenefit.related-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.related.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.related.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.related.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.related.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Reference to a related claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.claim-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Reference to the related claim",
"type": "reference",
"linkId": "ExplanationOfBenefit.related.claim.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Claim"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.related.claim",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "A code to convey how the claims are related. For example, prior claim or umbrella.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.relationship-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.related.relationship.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.related.relationship.text",
"repeats": false,
"required": false
} ],
"text": "How the reference claim is related",
"type": "group",
"linkId": "ExplanationOfBenefit.related.relationship",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "An alternate organizational reference to the case or file to which this particular claim pertains. For example, Property/Casualty insurer claim number or Workers Compensation case number.",
"type": "display",
"linkId": "ExplanationOfBenefit.related.reference-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.related.reference.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.related.reference.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.related.reference.value",
"repeats": false,
"required": false
} ],
"text": "File or case reference",
"type": "group",
"linkId": "ExplanationOfBenefit.related.reference",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
} ],
"text": "Prior or corollary claims",
"type": "group",
"linkId": "ExplanationOfBenefit.related",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.",
"type": "display",
"linkId": "ExplanationOfBenefit.prescription-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Prescription authorizing services or products",
"type": "reference",
"linkId": "ExplanationOfBenefit.prescription.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "MedicationRequest, VisionPrescription"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.prescription",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"type": "display",
"linkId": "ExplanationOfBenefit.originalPrescription-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Original prescription if superceded by fulfiller",
"type": "reference",
"linkId": "ExplanationOfBenefit.originalPrescription.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "MedicationRequest"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.originalPrescription",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Information code for an event with a corresponding date or period.",
"type": "display",
"linkId": "ExplanationOfBenefit.event-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.event.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.event.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.event.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.event.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.event.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.event.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.event.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A coded event such as when a service is expected or a card printed.",
"type": "display",
"linkId": "ExplanationOfBenefit.event.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.event.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.event.type.text",
"repeats": false,
"required": false
} ],
"text": "Specific event",
"type": "group",
"linkId": "ExplanationOfBenefit.event.type",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A date or period in the past or future indicating when the event occurred or is expectd to occur.",
"type": "display",
"linkId": "ExplanationOfBenefit.event.when[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "dateTime",
"linkId": "ExplanationOfBenefit.event.when[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.event.when[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.event.when[x]._null.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.event.when[x]._null.end",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.event.when[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.event.when[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs2",
"answerConstraint": "optionsOnly"
} ],
"text": "Occurance date or period",
"type": "group",
"linkId": "ExplanationOfBenefit.event.when[x]",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
} ],
"text": "Event information",
"type": "group",
"linkId": "ExplanationOfBenefit.event",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee-display"
}, {
"text": "The party to be reimbursed for cost of the products and services according to the terms of the policy.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.payee.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.payee.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.payee.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.payee.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Type of Party to be reimbursed: Subscriber, provider, other.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.payee.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.payee.type.text",
"repeats": false,
"required": false
} ],
"text": "Category of recipient",
"type": "group",
"linkId": "ExplanationOfBenefit.payee.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference to the individual or organization to whom any payment will be made. Not required if the payee is 'subscriber' or 'provider'.",
"type": "display",
"linkId": "ExplanationOfBenefit.payee.party-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Recipient reference",
"type": "reference",
"linkId": "ExplanationOfBenefit.payee.party.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Practitioner, PractitionerRole, Organization, Patient, RelatedPerson"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.payee.party",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "Recipient of benefits payable",
"type": "group",
"linkId": "ExplanationOfBenefit.payee",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services. The referral resource which lists the date, practitioner, reason and other supporting information.",
"type": "display",
"linkId": "ExplanationOfBenefit.referral-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Treatment Referral",
"type": "reference",
"linkId": "ExplanationOfBenefit.referral.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "ServiceRequest"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.referral",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Healthcare encounters related to this claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.encounter-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Encounters associated with the listed treatments",
"type": "reference",
"linkId": "ExplanationOfBenefit.encounter.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Encounter"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.encounter",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Facility where the services were provided.",
"type": "display",
"linkId": "ExplanationOfBenefit.facility-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Servicing Facility",
"type": "reference",
"linkId": "ExplanationOfBenefit.facility.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Location, Organization"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.facility",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.",
"type": "display",
"linkId": "ExplanationOfBenefit.claim-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Claim reference",
"type": "reference",
"linkId": "ExplanationOfBenefit.claim.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Claim"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.claim",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.",
"type": "display",
"linkId": "ExplanationOfBenefit.claimResponse-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Claim response reference",
"type": "reference",
"linkId": "ExplanationOfBenefit.claimResponse.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "ClaimResponse"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.claimResponse",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The outcome of the claim, predetermination, or preauthorization processing. The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).",
"type": "display",
"linkId": "ExplanationOfBenefit.outcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "outcome",
"type": "coding",
"linkId": "ExplanationOfBenefit.outcome.value",
"repeats": false,
"required": false,
"answerConstraint": "optionsOrType"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.outcome",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
} ]
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A human readable description of the status of the adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.disposition-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Disposition Message",
"type": "string",
"linkId": "ExplanationOfBenefit.disposition.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.disposition",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.preAuthRefPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.preAuthRefPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.preAuthRefPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization in-effect period",
"type": "group",
"linkId": "ExplanationOfBenefit.preAuthRefPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
}, {
"item": [ {
"text": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system. For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosisRelatedGroup-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.diagnosisRelatedGroup.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.diagnosisRelatedGroup.text",
"repeats": false,
"required": false
} ],
"text": "Package billing code",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosisRelatedGroup",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The members of the team who provided the products and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.careTeam.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify care team entries.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Order of care team",
"type": "integer",
"linkId": "ExplanationOfBenefit.careTeam.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Member of the team who provided the product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.provider-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Practitioner or organization",
"type": "reference",
"linkId": "ExplanationOfBenefit.careTeam.provider.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Practitioner, PractitionerRole, Organization"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.provider",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The party who is billing and/or responsible for the claimed products or services. Responsible might not be required when there is only a single provider listed.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.responsible-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Indicator of the lead practitioner",
"type": "boolean",
"linkId": "ExplanationOfBenefit.careTeam.responsible.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.responsible",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
} ]
}, {
"item": [ {
"text": "The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. Role might not be required when there is only a single provider listed.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.role-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.careTeam.role.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.careTeam.role.text",
"repeats": false,
"required": false
} ],
"text": "Function within the team",
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.role",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The specialization of the practitioner or provider which is applicable for this service.",
"type": "display",
"linkId": "ExplanationOfBenefit.careTeam.specialty-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.careTeam.specialty.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.careTeam.specialty.text",
"repeats": false,
"required": false
} ],
"text": "Practitioner or provider specialization",
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam.specialty",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
} ],
"text": "Care Team members",
"type": "group",
"linkId": "ExplanationOfBenefit.careTeam",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Often there are multiple jurisdiction specific valuesets which are required.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo-display"
}, {
"text": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify supporting information entries.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Information instance identifier",
"type": "integer",
"linkId": "ExplanationOfBenefit.supportingInfo.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The general class of the information supplied: information; exception; accident, employment; onset, etc. This may contain a category for the local bill type codes.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.category.text",
"repeats": false,
"required": false
} ],
"text": "Classification of the supplied information",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.code-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.code.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.code.text",
"repeats": false,
"required": false
} ],
"text": "Type of information",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.code",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The date when or period to which this information refers.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "dateTime",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._null.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._null.end",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs3",
"answerConstraint": "optionsOnly"
} ],
"text": "When it occurred",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.timing[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "boolean",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
} ]
}, {
"item": [ {
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.system",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Attachment"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Resource"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs4",
"answerConstraint": "optionsOnly"
} ],
"text": "Data to be provided",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.value[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "Provides the reason in the situation where a reason code is required in addition to the content. For example: the reason for the additional stay, or why a tooth is missing.",
"type": "display",
"linkId": "ExplanationOfBenefit.supportingInfo.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Explanation for the information",
"type": "coding",
"linkId": "ExplanationOfBenefit.supportingInfo.reason.value",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
} ]
} ],
"text": "Supporting information",
"type": "group",
"linkId": "ExplanationOfBenefit.supportingInfo",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Information about diagnoses relevant to the claim items.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.diagnosis.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify diagnosis entries. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Diagnosis instance identifier",
"type": "integer",
"linkId": "ExplanationOfBenefit.diagnosis.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._null.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._null.text",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Condition"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs5",
"answerConstraint": "optionsOnly"
} ],
"text": "Nature of illness or problem",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "When the condition was observed or the relative ranking. For example: admitting, primary, secondary, discharge.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.diagnosis.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.diagnosis.type.text",
"repeats": false,
"required": false
} ],
"text": "Timing or nature of the diagnosis",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Indication of whether the diagnosis was present on admission to a facility.",
"type": "display",
"linkId": "ExplanationOfBenefit.diagnosis.onAdmission-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.diagnosis.onAdmission.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.diagnosis.onAdmission.text",
"repeats": false,
"required": false
} ],
"text": "Present on admission",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis.onAdmission",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
} ],
"text": "Pertinent diagnosis information",
"type": "group",
"linkId": "ExplanationOfBenefit.diagnosis",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Procedures performed on the patient relevant to the billing items with the claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.procedure.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify procedure entries.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Procedure instance identifier",
"type": "integer",
"linkId": "ExplanationOfBenefit.procedure.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "When the condition was observed or the relative ranking.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.procedure.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.procedure.type.text",
"repeats": false,
"required": false
} ],
"text": "Category of Procedure",
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Date and optionally time the procedure was performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.date-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "When the procedure was performed",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.procedure.date.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.date",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "The code or reference to a Procedure resource which identifies the clinical intervention performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._null.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._null.text",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Procedure"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs6",
"answerConstraint": "optionsOnly"
} ],
"text": "Specific clinical procedure",
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.procedure[x]",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "Unique Device Identifiers associated with this line item.",
"type": "display",
"linkId": "ExplanationOfBenefit.procedure.udi-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique device identifier",
"type": "reference",
"linkId": "ExplanationOfBenefit.procedure.udi.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Device"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.procedure.udi",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "Clinical procedures performed",
"type": "group",
"linkId": "ExplanationOfBenefit.procedure",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.",
"type": "display",
"linkId": "ExplanationOfBenefit.precedence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Precedence (primary, secondary, etc.)",
"type": "integer",
"linkId": "ExplanationOfBenefit.precedence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.precedence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance-display"
}, {
"text": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.insurance.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.focal-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Coverage to be used for adjudication",
"type": "boolean",
"linkId": "ExplanationOfBenefit.insurance.focal.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.focal",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
} ]
}, {
"item": [ {
"text": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.coverage-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Insurance information",
"type": "reference",
"linkId": "ExplanationOfBenefit.insurance.coverage.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Coverage"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.coverage",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.",
"type": "display",
"linkId": "ExplanationOfBenefit.insurance.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Prior authorization reference number",
"type": "string",
"linkId": "ExplanationOfBenefit.insurance.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.insurance.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
} ],
"text": "Patient insurance information",
"type": "group",
"linkId": "ExplanationOfBenefit.insurance",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Details of a accident which resulted in injuries which required the products and services listed in the claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.accident.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.accident.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.accident.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Date of an accident event related to the products and services contained in the claim. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.date-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "When the incident occurred",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.accident.date.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.accident.date",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.accident.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.type.text",
"repeats": false,
"required": false
} ],
"text": "The nature of the accident",
"type": "group",
"linkId": "ExplanationOfBenefit.accident.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The physical location of the accident event.",
"type": "display",
"linkId": "ExplanationOfBenefit.accident.location[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.text",
"repeats": false,
"required": false
}, {
"text": "line:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.line",
"repeats": true,
"required": false
}, {
"text": "city:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.city",
"repeats": false,
"required": false
}, {
"text": "state:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.state",
"repeats": false,
"required": false
}, {
"text": "post code:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.postalCode",
"repeats": false,
"required": false
}, {
"text": "country:",
"type": "string",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.country",
"repeats": false,
"required": false
}, {
"text": "use:",
"type": "coding",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.use",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.accident.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Address"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.accident.location[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Location"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.accident.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.accident.location[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs7",
"answerConstraint": "optionsOnly"
} ],
"text": "Where the event occurred",
"type": "group",
"linkId": "ExplanationOfBenefit.accident.location[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
} ],
"text": "Details of the event",
"type": "group",
"linkId": "ExplanationOfBenefit.accident",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.",
"type": "display",
"linkId": "ExplanationOfBenefit.item-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify item entries.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Item instance identifier",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Care team members related to this service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.careTeamSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable care team members",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.careTeamSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.careTeamSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Diagnoses applicable for this service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.diagnosisSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable diagnoses",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.diagnosisSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.diagnosisSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Procedures applicable for this service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.procedureSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable procedures",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.procedureSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.procedureSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Exceptions, special conditions and supporting information applicable for this service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.informationSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable exception and supporting information",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.informationSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.informationSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.item.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.category.text",
"repeats": false,
"required": false
} ],
"text": "Benefit classification",
"type": "group",
"linkId": "ExplanationOfBenefit.item.category",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.item.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Request or Referral for Goods or Service to be rendered.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.request-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Request or Referral for Service",
"type": "reference",
"linkId": "ExplanationOfBenefit.item.request.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, SupplyRequest, VisionPrescription"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.request",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Product or service billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.item.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.programCode-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.programCode.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.programCode.text",
"repeats": false,
"required": false
} ],
"text": "Program the product or service is provided under",
"type": "group",
"linkId": "ExplanationOfBenefit.item.programCode",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The date or dates when the service or product was supplied, performed or completed.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.serviced[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.serviced[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.serviced[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.serviced[x]._null.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.serviced[x]._null.end",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.serviced[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.serviced[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs8",
"answerConstraint": "optionsOnly"
} ],
"text": "Date or dates of service or product delivery",
"type": "group",
"linkId": "ExplanationOfBenefit.item.serviced[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "Where the product or service was provided.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.location[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.location[x]._null.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.text",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.text",
"repeats": false,
"required": false
}, {
"text": "line:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.line",
"repeats": true,
"required": false
}, {
"text": "city:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.city",
"repeats": false,
"required": false
}, {
"text": "state:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.state",
"repeats": false,
"required": false
}, {
"text": "post code:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.postalCode",
"repeats": false,
"required": false
}, {
"text": "country:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.location[x]._null.country",
"repeats": false,
"required": false
}, {
"text": "use:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.location[x]._null.use",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Address"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.item.location[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Location"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.location[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs9",
"answerConstraint": "optionsOnly"
} ],
"text": "Place of service or where product was supplied",
"type": "group",
"linkId": "ExplanationOfBenefit.item.location[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.item.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.item.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.item.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.item.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.item.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Unique Device Identifiers associated with this line item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.udi-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique device identifier",
"type": "reference",
"linkId": "ExplanationOfBenefit.item.udi.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Device"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.udi",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Physical location where the service is performed or applies.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.bodySite.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.site-display"
}, {
"text": "Physical service site on the patient (limb, tooth, etc.).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.site-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Location",
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite.site",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.bodySite.subSite-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.bodySite.subSite.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.bodySite.subSite.text",
"repeats": false,
"required": false
} ],
"text": "Sub-location",
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite.subSite",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
} ],
"text": "Anatomical location",
"type": "group",
"linkId": "ExplanationOfBenefit.item.bodySite",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Healthcare encounters related to this claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.encounter-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Encounters associated with the listed treatments",
"type": "reference",
"linkId": "ExplanationOfBenefit.item.encounter.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Encounter"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.encounter",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Adjudication details",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Second-tier of goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Product or service provided",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.detail.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Code to identify the general type of benefits under which products and services are provided. Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.category.text",
"repeats": false,
"required": false
} ],
"text": "Benefit classification",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.category",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Service/Product billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.programCode-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.programCode.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.programCode.text",
"repeats": false,
"required": false
} ],
"text": "Program the product or service is provided under",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.programCode",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Unique Device Identifiers associated with this line item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.udi-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique device identifier",
"type": "reference",
"linkId": "ExplanationOfBenefit.item.detail.udi.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Device"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.udi",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.detail.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Detail level adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The adjudication results.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Detail level adjudication details",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.adjudication",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Third-tier of goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.sequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Product or service provided",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.sequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category.text",
"repeats": false,
"required": false
} ],
"text": "Benefit classification",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Service/Product billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode.text",
"repeats": false,
"required": false
} ],
"text": "Program the product or service is provided under",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Unique Device Identifiers associated with this line item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.udi-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique device identifier",
"type": "reference",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.udi.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Device"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.udi",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Subdetail level adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The adjudication results.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Subdetail level adjudication details",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"repeats": true,
"required": false
} ],
"text": "Additional items",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail.subDetail",
"repeats": true,
"required": false
} ],
"text": "Additional items",
"type": "group",
"linkId": "ExplanationOfBenefit.item.detail",
"repeats": true,
"required": false
} ],
"text": "Product or service provided",
"type": "group",
"linkId": "ExplanationOfBenefit.item",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The first-tier service adjudications for payor added product or service lines.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Claim items which this service line is intended to replace.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.itemSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Item sequence number",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.itemSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.itemSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The sequence number of the details within the claim item which this line is intended to replace.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detailSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Detail sequence number",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.detailSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detailSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.subDetailSequence-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Subdetail sequence number",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.subDetailSequence.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.subDetailSequence",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The providers who are authorized for the services rendered to the patient.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.provider-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Authorized providers",
"type": "reference",
"linkId": "ExplanationOfBenefit.addItem.provider.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Practitioner, PractitionerRole, Organization"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.provider",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Request or Referral for Goods or Service to be rendered.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.request-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Request or Referral for Service",
"type": "reference",
"linkId": "ExplanationOfBenefit.addItem.request.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, SupplyRequest, VisionPrescription"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.request",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Service/Product billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.programCode-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.programCode.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.programCode.text",
"repeats": false,
"required": false
} ],
"text": "Program the product or service is provided under",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.programCode",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The date or dates when the service or product was supplied, performed or completed.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "dateTime",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._null.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._null.end",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs10",
"answerConstraint": "optionsOnly"
} ],
"text": "Date or dates of service or product delivery",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.serviced[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "Where the product or service was provided.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.location[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.text",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.text",
"repeats": false,
"required": false
}, {
"text": "line:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.line",
"repeats": true,
"required": false
}, {
"text": "city:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.city",
"repeats": false,
"required": false
}, {
"text": "state:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.state",
"repeats": false,
"required": false
}, {
"text": "post code:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.postalCode",
"repeats": false,
"required": false
}, {
"text": "country:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.country",
"repeats": false,
"required": false
}, {
"text": "use:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.use",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Address"
} ]
}, {
"item": [ {
"type": "reference",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null.value",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode": "Location"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
} ]
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.location[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.location[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs11",
"answerConstraint": "optionsOnly"
} ],
"text": "Place of service or where product was supplied",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.location[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Physical location where the service is performed or applies.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.bodySite.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.site-display"
}, {
"text": "Physical service site on the patient (limb, tooth, etc.).",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.site-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Location",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite.site",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.bodySite.subSite-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.bodySite.subSite.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.bodySite.subSite.text",
"repeats": false,
"required": false
} ],
"text": "Sub-location",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite.subSite",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
} ],
"text": "Anatomical location",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.bodySite",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Additem level adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The adjudication results.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Added items adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.adjudication",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The second-tier service adjudications for payor added services.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Service/Product billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.detail.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Additem detail level adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The adjudication results.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Added items adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.adjudication",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The third-tier service adjudications for payor added services.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber.value",
"repeats": false,
"required": false
} ],
"text": "Number for tracking",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
}, {
"item": [ {
"text": "The type of revenue or cost center providing the product and/or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.revenue-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.revenue.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.revenue.text",
"repeats": false,
"required": false
} ],
"text": "Revenue or cost center code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.revenue",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService.text",
"repeats": false,
"required": false
} ],
"text": "Billing, service, product, or drug code",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd.text",
"repeats": false,
"required": false
} ],
"text": "End of a range of codes",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Item typification or modifiers codes to convey additional context for the product or service. For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifier.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifier.text",
"repeats": false,
"required": false
} ],
"text": "Service/Product billing modifiers",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.modifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid.system",
"repeats": false,
"required": false
} ],
"text": "Paid by the patient",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The number of repetitions of a service or product.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Count of products or services",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice.system",
"repeats": false,
"required": false
} ],
"text": "Fee, charge or cost per item",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.factor-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Price scaling factor",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.factor.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.factor",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
} ]
}, {
"item": [ {
"text": "The total of taxes applicable for this product or service.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax.system",
"repeats": false,
"required": false
} ],
"text": "Total tax",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.tax",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net.system",
"repeats": false,
"required": false
} ],
"text": "Total item cost",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.net",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "The numbers associated with notes below which apply to the adjudication of this item.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Applicable note numbers",
"type": "integer",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The high-level results of the adjudication if adjudication has been performed.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The result of the claim, predetermination, or preauthorization adjudication. The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision.text",
"repeats": false,
"required": false
} ],
"text": "Result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.decision",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason.text",
"repeats": false,
"required": false
} ],
"text": "Reason for result of the adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Preauthorization reference",
"type": "string",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "The time frame during which this authorization is effective.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod.end",
"repeats": false,
"required": false
} ],
"text": "Preauthorization reference effective period",
"type": "group",
"linkId": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
} ],
"text": "Additem subdetail level adjudication results",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The adjudication results.",
"type": "display",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Added items adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication",
"repeats": true,
"required": false
} ],
"text": "Insurer added line items",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail.subDetail",
"repeats": true,
"required": false
} ],
"text": "Insurer added line items",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem.detail",
"repeats": true,
"required": false
} ],
"text": "Insurer added line items",
"type": "group",
"linkId": "ExplanationOfBenefit.addItem",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The adjudication results which are presented at the header level rather than at the line-item or add-item levels.",
"type": "display",
"linkId": "ExplanationOfBenefit.adjudication-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.reason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.reason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation of adjudication outcome",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"repeats": false,
"required": false
} ],
"text": "Monetary amount",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.",
"type": "display",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity.system",
"repeats": false,
"required": false
} ],
"text": "Non-monitary value",
"type": "group",
"linkId": "ExplanationOfBenefit.item.adjudication.quantity",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Header-level adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.adjudication",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Totals for amounts submitted, co-pays, benefits payable etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.total-display"
}, {
"text": "Categorized monetary totals for the adjudication.",
"type": "display",
"linkId": "ExplanationOfBenefit.total-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.total.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.total.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.total.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.total.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.total.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.total.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.total.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"type": "display",
"linkId": "ExplanationOfBenefit.total.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.total.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.total.category.text",
"repeats": false,
"required": false
} ],
"text": "Type of adjudication information",
"type": "group",
"linkId": "ExplanationOfBenefit.total.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Monetary total amount associated with the category.",
"type": "display",
"linkId": "ExplanationOfBenefit.total.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.total.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.total.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.total.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.total.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.total.amount.system",
"repeats": false,
"required": false
} ],
"text": "Financial total for the category",
"type": "group",
"linkId": "ExplanationOfBenefit.total.amount",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "Adjudication totals",
"type": "group",
"linkId": "ExplanationOfBenefit.total",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Payment details for the adjudication of the claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.payment.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Whether this represents partial or complete payment of the benefits payable.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.payment.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.type.text",
"repeats": false,
"required": false
} ],
"text": "Partial or complete payment",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.adjustment-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.payment.adjustment.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.payment.adjustment.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.adjustment.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.adjustment.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.adjustment.system",
"repeats": false,
"required": false
} ],
"text": "Payment adjustment for non-claim issues",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.adjustment",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Reason for the payment adjustment.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.adjustmentReason-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.payment.adjustmentReason.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.adjustmentReason.text",
"repeats": false,
"required": false
} ],
"text": "Explanation for the variance",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.adjustmentReason",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Estimated date the payment will be issued or the actual issue date of payment.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.date-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Expected date of payment",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.payment.date.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.payment.date",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
} ]
}, {
"item": [ {
"text": "Benefits payable less any payment adjustment.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.amount-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.payment.amount.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.payment.amount.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.amount.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.amount.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.amount.system",
"repeats": false,
"required": false
} ],
"text": "Payable amount after adjustment",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.amount",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
}, {
"item": [ {
"text": "Issuer's unique identifier for the payment instrument. For example: EFT number or check number.",
"type": "display",
"linkId": "ExplanationOfBenefit.payment.identifier-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "label:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.identifier.label",
"repeats": false,
"required": false
}, {
"text": "system:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.identifier.system",
"repeats": false,
"required": false
}, {
"text": "value:",
"type": "string",
"linkId": "ExplanationOfBenefit.payment.identifier.value",
"repeats": false,
"required": false
} ],
"text": "Business identifier for the payment",
"type": "group",
"linkId": "ExplanationOfBenefit.payment.identifier",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
} ]
} ],
"text": "Payment Details",
"type": "group",
"linkId": "ExplanationOfBenefit.payment",
"repeats": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "A code for the form to be used for printing the content. May be needed to identify specific jurisdictional forms.",
"type": "display",
"linkId": "ExplanationOfBenefit.formCode-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.formCode.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.formCode.text",
"repeats": false,
"required": false
} ],
"text": "Printed form identifier",
"type": "group",
"linkId": "ExplanationOfBenefit.formCode",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The actual form, by reference or inclusion, for printing the content or an EOB. Needed to permit insurers to include the actual form.",
"type": "display",
"linkId": "ExplanationOfBenefit.form-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Printed reference or actual form",
"type": "group",
"linkId": "ExplanationOfBenefit.form",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Attachment"
} ]
}, {
"item": [ {
"text": "A note that describes or explains adjudication results in a human readable form.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.processNote.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "A number to uniquely identify a note entry.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.number-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Note instance identifier",
"type": "integer",
"linkId": "ExplanationOfBenefit.processNote.number.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.number",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "The business purpose of the note text.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.processNote.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.processNote.type.text",
"repeats": false,
"required": false
} ],
"text": "Note purpose",
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.type",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The explanation or description associated with the processing.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.text-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Note explanatory text",
"type": "string",
"linkId": "ExplanationOfBenefit.processNote.text.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.text",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "A code to define the language used in the text of the note. Only required if the language is different from the resource language.",
"type": "display",
"linkId": "ExplanationOfBenefit.processNote.language-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.processNote.language.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOrType"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.processNote.language.text",
"repeats": false,
"required": false
} ],
"text": "Language of the text",
"type": "group",
"linkId": "ExplanationOfBenefit.processNote.language",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
} ],
"text": "Note concerning adjudication",
"type": "group",
"linkId": "ExplanationOfBenefit.processNote",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "The term of the benefits documented in this response. Not applicable when use=claim.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitPeriod-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "start:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.benefitPeriod.low",
"repeats": false,
"required": false
}, {
"text": "end:",
"type": "dateTime",
"linkId": "ExplanationOfBenefit.benefitPeriod.end",
"repeats": false,
"required": false
} ],
"text": "When the benefits are applicable",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitPeriod",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
} ]
}, {
"item": [ {
"text": "Balance by Benefit Category.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.category-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.category.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.category.text",
"repeats": false,
"required": false
} ],
"text": "Benefit classification",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.category",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.excluded-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Excluded from the plan",
"type": "boolean",
"linkId": "ExplanationOfBenefit.benefitBalance.excluded.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.excluded",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
} ]
}, {
"item": [ {
"text": "A short name or tag for the benefit. For example: MED01, or DENT2.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.name-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Short name for the benefit",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.name.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.name",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "A richer description of the benefit or services covered. For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.description-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Description of the benefit or services covered",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.description.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.description",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.network-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.network.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.network.text",
"repeats": false,
"required": false
} ],
"text": "In or out of network",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.network",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Indicates if the benefits apply to an individual or to the family.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.unit-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.unit.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.unit.text",
"repeats": false,
"required": false
} ],
"text": "Individual or family",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.unit",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.term-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.term.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.term.text",
"repeats": false,
"required": false
} ],
"text": "Annual or lifetime",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.term",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "Benefits Used to date.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"text": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.id-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "Unique id for inter-element referencing",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.id.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.id",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.extension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Additional content defined by implementations",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.extension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
} ],
"text": "Extensions that cannot be ignored even if unrecognized",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Classification of benefit being provided. For example: deductible, visits, benefit amount.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"text": "code:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type.coding",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "text:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type.text",
"repeats": false,
"required": false
} ],
"text": "Benefit classification",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type",
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "CodeableConcept"
} ]
}, {
"item": [ {
"text": "The quantity of the benefit which is permitted under the coverage.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "integer",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
} ]
}, {
"item": [ {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null.system",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs12",
"answerConstraint": "optionsOnly"
} ],
"text": "Benefits allowed",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
}, {
"item": [ {
"text": "The quantity of the benefit which have been consumed to date.",
"type": "display",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]-flyover",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "flyover",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Fly-over"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "integer",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.value",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
} ]
}, {
"item": [ {
"text": "comp:",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.comparator",
"repeats": false,
"required": false,
"answerConstraint": "optionsOnly"
}, {
"text": "value:",
"type": "decimal",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.value",
"repeats": false,
"required": false
}, {
"text": "units:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.units",
"repeats": false,
"required": false
}, {
"text": "coded units:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.code",
"repeats": false,
"required": false
}, {
"text": "units system:",
"type": "string",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null.system",
"repeats": false,
"required": false
} ],
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._null",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
} ]
} ],
"text": "type",
"type": "coding",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]._type",
"repeats": false,
"required": false,
"answerValueSet": "#vs13",
"answerConstraint": "optionsOnly"
} ],
"text": "Benefits used",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"repeats": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
} ]
} ],
"text": "Benefit Summary",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance.financial",
"repeats": true,
"required": false
} ],
"text": "Balance by Benefit Category",
"type": "group",
"linkId": "ExplanationOfBenefit.benefitBalance",
"repeats": true,
"required": false
} ],
"text": "Explanation of Benefit resource",
"type": "group",
"linkId": "ExplanationOfBenefit",
"repeats": true,
"required": false
} ],
"type": null,
"experimental": "false",
"resourceType": "Questionnaire",
"title": null,
"package_version": "6.0.0-ballot3",
"contained": [ {
"id": "vs2",
"name": "Type options for ExplanationOfBenefit.event.when[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "dateTime",
"system": "http://hl7.org/fhir/fhir-types",
"display": "dateTime"
}, {
"code": "Period",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Period"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:971aff06-7a2c-4a49-a841-a886a1552497"
},
"description": "Type options for ExplanationOfBenefit.event.when[x]",
"resourceType": "ValueSet"
}, {
"id": "vs3",
"name": "Type options for ExplanationOfBenefit.supportingInfo.timing[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "date",
"system": "http://hl7.org/fhir/fhir-types",
"display": "date"
}, {
"code": "Period",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Period"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:f5cb653d-837a-4206-a73c-ac86b4192c97"
},
"description": "Type options for ExplanationOfBenefit.supportingInfo.timing[x]",
"resourceType": "ValueSet"
}, {
"id": "vs4",
"name": "Type options for ExplanationOfBenefit.supportingInfo.value[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "boolean",
"system": "http://hl7.org/fhir/fhir-types",
"display": "boolean"
}, {
"code": "string",
"system": "http://hl7.org/fhir/fhir-types",
"display": "string"
}, {
"code": "Quantity",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Quantity"
}, {
"code": "Attachment",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Attachment"
}, {
"code": "Resource",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Resource"
}, {
"code": "Identifier",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Identifier"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:d0ae6dcb-cd71-45df-bc6d-e9a2a273415f"
},
"description": "Type options for ExplanationOfBenefit.supportingInfo.value[x]",
"resourceType": "ValueSet"
}, {
"id": "vs5",
"name": "Type options for ExplanationOfBenefit.diagnosis.diagnosis[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "CodeableConcept",
"system": "http://hl7.org/fhir/fhir-types",
"display": "CodeableConcept"
}, {
"code": "Condition",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Condition"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:dca91f1e-0169-4695-a01d-c81d744dbc44"
},
"description": "Type options for ExplanationOfBenefit.diagnosis.diagnosis[x]",
"resourceType": "ValueSet"
}, {
"id": "vs6",
"name": "Type options for ExplanationOfBenefit.procedure.procedure[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "CodeableConcept",
"system": "http://hl7.org/fhir/fhir-types",
"display": "CodeableConcept"
}, {
"code": "Procedure",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Procedure"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:f4eeeabc-256a-495b-b95d-a513b577df2f"
},
"description": "Type options for ExplanationOfBenefit.procedure.procedure[x]",
"resourceType": "ValueSet"
}, {
"id": "vs7",
"name": "Type options for ExplanationOfBenefit.accident.location[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "Address",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Address"
}, {
"code": "Location",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Location"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:c21cc1dc-1152-4a64-a128-8f5740c098c8"
},
"description": "Type options for ExplanationOfBenefit.accident.location[x]",
"resourceType": "ValueSet"
}, {
"id": "vs8",
"name": "Type options for ExplanationOfBenefit.item.serviced[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "date",
"system": "http://hl7.org/fhir/fhir-types",
"display": "date"
}, {
"code": "Period",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Period"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:873e1220-08b7-41a0-afc1-d246e0608e95"
},
"description": "Type options for ExplanationOfBenefit.item.serviced[x]",
"resourceType": "ValueSet"
}, {
"id": "vs9",
"name": "Type options for ExplanationOfBenefit.item.location[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "CodeableConcept",
"system": "http://hl7.org/fhir/fhir-types",
"display": "CodeableConcept"
}, {
"code": "Address",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Address"
}, {
"code": "Location",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Location"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:b0ac9a2f-9bd2-4aa1-8e9f-ee47d4b1003f"
},
"description": "Type options for ExplanationOfBenefit.item.location[x]",
"resourceType": "ValueSet"
}, {
"id": "vs10",
"name": "Type options for ExplanationOfBenefit.addItem.serviced[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "date",
"system": "http://hl7.org/fhir/fhir-types",
"display": "date"
}, {
"code": "Period",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Period"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:74ac77d1-3c30-4d12-ba8c-7f8df4701715"
},
"description": "Type options for ExplanationOfBenefit.addItem.serviced[x]",
"resourceType": "ValueSet"
}, {
"id": "vs11",
"name": "Type options for ExplanationOfBenefit.addItem.location[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "CodeableConcept",
"system": "http://hl7.org/fhir/fhir-types",
"display": "CodeableConcept"
}, {
"code": "Address",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Address"
}, {
"code": "Location",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Location"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:047e1110-a569-4fb1-8dd8-bd8ed013ed47"
},
"description": "Type options for ExplanationOfBenefit.addItem.location[x]",
"resourceType": "ValueSet"
}, {
"id": "vs12",
"name": "Type options for ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "unsignedInt",
"system": "http://hl7.org/fhir/fhir-types",
"display": "unsignedInt"
}, {
"code": "string",
"system": "http://hl7.org/fhir/fhir-types",
"display": "string"
}, {
"code": "Money",
"system": "http://hl7.org/fhir/fhir-types",
"display": "Money"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:ed73a57a-f037-4fc4-924e-6e2c55083531"
},
"description": "Type options for ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"resourceType": "ValueSet"
}, {
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"name": "Type options for ExplanationOfBenefit.benefitBalance.financial.used[x]",
"status": "active",
"expansion": {
"contains": [ {
"code": "unsignedInt",
"system": "http://hl7.org/fhir/fhir-types",
"display": "unsignedInt"
}, {
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"system": "http://hl7.org/fhir/fhir-types",
"display": "Money"
} ],
"timestamp": "2025-04-01T12:25:09+11:00",
"identifier": "urn:uuid:66d26166-cc7c-4e8f-a737-1c4588ccfa3a"
},
"description": "Type options for ExplanationOfBenefit.benefitBalance.financial.used[x]",
"resourceType": "ValueSet"
} ],
"status": "draft",
"id": "2ee1551d-9960-4821-b7a6-3f87cc698b76",
"kind": null,
"url": "http://hl7.org/fhir/Questionnaire/qgen-ExplanationOfBenefit1",
"identifier": [ {
"system": "urn:ietf:rfc:3986"
} ],
"version": "6.0.0-ballot3"
}