description: This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan.
package_name: hl7.fhir.us.carin-bb
derivation: constraint
name: C4BBExplanationOfBenefitOral
type: ExplanationOfBenefit
elements:
  diagnosis:
    mustSupport: true
    index: 56
    elements:
      sequence: {index: 57}
      diagnosis:
        mustSupport: true
        choices: [diagnosisCodeableConcept]
        index: 59
      diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 60}
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType'}
        mustSupport: true
        index: 61
    required: [type]
  meta:
    elements:
      profile:
        pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0'}
        index: 0
        slicing:
          slices:
            supportedProfile:
              match: {}
              schema:
                pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0'}
                index: 0
  adjudication: {index: 86}
  supportingInfo:
    array: true
    min: 3
    index: 6
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: category, type: pattern}
      min: 3
      slices:
        missingtoothnumber:
          match:
            category:
              coding:
              - {code: missingtoothnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Missing tooth number
            mustSupport: true
            array: true
            index: 41
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: missingtoothnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 42
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem'}
                mustSupport: true
                index: 43
            required: [code]
        performingnetworkcontractingstatus:
          match:
            category:
              coding:
              - {code: performingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Performing provider contracting status
            mustSupport: true
            _required: true
            index: 10
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: performingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 11
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'}
                mustSupport: true
                index: 12
            required: [code]
        orthodontics:
          match:
            category:
              coding:
              - {code: orthodontics, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Orthodontics treatment indicator
            mustSupport: true
            index: 23
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: orthodontics, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 24
              code: {index: 25}
              timingDate: {type: date, short: Orthodontics appliance application date (200), index: 26}
              value:
                mustSupport: true
                choices: [valueQuantity]
                index: 28
              valueQuantity: {type: Quantity, mustSupport: true, choiceOf: value, index: 29}
            required: [value, valueQuantity]
        additionalbodysite:
          match:
            category:
              coding:
              - {code: additionalbodysite, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Additional tooth number or oral cavity code
            mustSupport: true
            array: true
            index: 38
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: additionalbodysite, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 39
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite'}
                mustSupport: true
                index: 40
            required: [code]
        servicefacility:
          match:
            category:
              coding:
              - {code: servicefacility, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Service facility
            mustSupport: true
            index: 18
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: servicefacility, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 19
              value:
                choices: []
                index: 21
              valueReference:
                type: Reference
                mustSupport: true
                refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization']
                index: 22
            required: [valueReference, value]
        billingnetworkcontractingstatus:
          match:
            category:
              coding:
              - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Billing provider contracting status
            mustSupport: true
            _required: true
            index: 7
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 8
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'}
                mustSupport: true
                index: 9
            required: [code]
        prosthesis:
          match:
            category:
              coding:
              - {code: prosthesis, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Prosthesis
            mustSupport: true
            index: 31
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: prosthesis, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 32
              timingDate: {type: date, short: Date of prior prosthesis replacement  (203), index: 33}
              value:
                mustSupport: true
                choices: [valueBoolean]
                index: 35
              valueBoolean: {type: boolean, mustSupport: true, choiceOf: value, index: 36}
            required: [value, valueBoolean]
        clmrecvddate:
          match:
            category:
              coding:
              - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Claim received date
            mustSupport: true
            index: 13
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 14
              timing:
                mustSupport: true
                choices: [timingDate]
                index: 16
              timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 17}
            required: [timingDate, timing]
        benefitpaymentstatus:
          match: {category: null}
          schema:
            short: Indicates the in network or out of network payment status of the claim. (142)
            mustSupport: true
            array: true
            min: 1
            _required: true
            index: 54
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'}
                index: 55
        medicalrecordnumber:
          match:
            category:
              coding:
              - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Medical record number
            mustSupport: true
            index: 44
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 45
              value:
                choices: []
                index: 47
              valueString: {type: string, mustSupport: true, index: 48}
            required: [valueString, value]
        patientaccountnumber:
          match:
            category:
              coding:
              - {code: patientaccountnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            short: Patient account number
            mustSupport: true
            index: 49
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: patientaccountnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 50
              value:
                choices: []
                index: 52
              valueString: {type: string, mustSupport: true, index: 53}
            required: [valueString, value]
  item:
    elements:
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers'}
        mustSupport: true
        index: 64
      adjudication:
        mustSupport: true
        array: true
        min: 2
        index: 74
        elements:
          category:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'}
            index: 75
        slicing:
          rules: open
          ordered: false
          description: Slice based on value pattern
          discriminator:
          - {path: category, type: pattern}
          min: 2
          slices:
            adjudicationamounttype:
              match: {category: null}
              schema:
                short: Amounts
                mustSupport: true
                array: true
                min: 1
                _required: true
                index: 76
                elements:
                  category:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'}
                    index: 77
                  amount: {mustSupport: true, index: 78}
                required: [amount]
            denialreason:
              match:
                category:
                  coding:
                  - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
              schema:
                short: Reason codes used to interpret the Non-Covered Amount (92)
                mustSupport: true
                index: 79
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
                    index: 80
                  reason:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'}
                    mustSupport: true
                    index: 81
                required: [reason]
            benefitpaymentstatus:
              match: {category: null}
              schema:
                short: Indicates the in network or out of network payment status of the claim. (142)
                mustSupport: true
                _required: true
                index: 82
                elements:
                  category:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'}
                    index: 83
            allowedunits:
              match:
                category:
                  coding:
                  - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
              schema:
                short: The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider.  (149)
                mustSupport: true
                index: 84
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
                    index: 85
      locationCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: location, index: 69}
      serviced:
        choices: []
        index: 66
      subSite:
        short: Tooth surface for all teeth on line
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes'}
        index: 73
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode'}
        mustSupport: true
        index: 63
      informationSequence: {mustSupport: true, index: 62}
      bodySite:
        short: First tooth number or oral cavity code
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite'}
        index: 72
      quantity: {index: 71}
      location:
        mustSupport: true
        choices: [locationCodeableConcept]
        index: 68
    required: [location, locationCodeableConcept]
  type:
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: oral, system: 'http://terminology.hl7.org/CodeSystem/claim-type'}
    index: 1
  total:
    index: 87
    elements:
      category: {mustSupport: true, index: 88}
      amount: {index: 89}
    slicing:
      rules: open
      ordered: false
      description: Slice based on value pattern
      discriminator:
      - {path: category, type: pattern}
      min: null
      slices:
        adjudicationamounttype:
          match: {category: null}
          schema:
            short: Total adjudication type and amount
            mustSupport: true
            array: true
            min: 1
            _required: true
            index: 90
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'}
                index: 91
  provider:
    type: Reference
    refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner']
    index: 2
  careTeam:
    constraint:
      EOB-prof-careTeam-practitioner:
        human: 'Professional EOB:  Careteam roles refer to a practitioner'
        source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral
        severity: error
        expression: |-
          (
          role.where(coding.where(code in ('performing' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies
          role.where(coding.where(code in ('performing' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner)
          )
    index: 3
    elements:
      role:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole'}
        index: 4
      qualification:
        binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066'}
        mustSupport: true
        index: 5
    required: [role]
package_version: 1.2.0
class: profile
kind: resource
url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral
base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit
version: 1.2.0