description: This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500. package_name: hl7.fhir.us.carin derivation: constraint name: C4BBExplanationOfBenefitProfessionalNonClinician type: ExplanationOfBenefit elements: diagnosis: mustSupport: true index: 34 elements: sequence: {index: 35} diagnosis: mustSupport: true choices: [diagnosisCodeableConcept] index: 37 diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 38} type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType'} mustSupport: true index: 39 required: [type] meta: elements: profile: pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0'} index: 0 slicing: slices: supportedProfile: match: {} schema: pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0'} index: 0 adjudication: {index: 61} supportingInfo: index: 7 slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: category, type: pattern} min: null slices: billingnetworkcontractingstatus: match: category: coding: - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Billing provider contracting status mustSupport: true index: 8 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 9 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'} mustSupport: true index: 10 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 index: 11 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: performingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 12 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'} mustSupport: true index: 13 required: [code] clmrecvddate: match: category: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Claim received date mustSupport: true index: 14 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 15 timing: mustSupport: true choices: [timingDate] index: 17 timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 18} required: [timingDate, timing] servicefacility: match: category: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Service facility mustSupport: true index: 19 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 20 value: choices: [] index: 22 valueReference: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization'] index: 23 required: [valueReference, value] medicalrecordnumber: match: category: coding: - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Medical record number mustSupport: true index: 24 elements: category: pattern: type: CodeableConcept value: coding: - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 25 value: choices: [] index: 27 valueString: {type: string, mustSupport: true, index: 28} 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: 29 elements: category: pattern: type: CodeableConcept value: coding: - {code: patientaccountnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 30 value: choices: [] index: 32 valueString: {type: string, mustSupport: true, index: 33} required: [valueString, value] item: elements: productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes'} constraint: EOB-vision-item-productorservice: {human: 'Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.', source: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician', severity: error, expression: 'ExplanationOfBenefit.subType.coding.where(code = ''vision'' and system=''http://terminology.hl7.org/CodeSystem/claim-type'').exists() or ExplanationOfBenefit.item.productOrService.coding.where(code = ''not-applicable'' and system = ''http://terminology.hl7.org/CodeSystem/data-absent-reason'').exists().not()'} mustSupport: true index: 40 modifier: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers'} mustSupport: true index: 41 serviced: choices: [] index: 43 location: mustSupport: true choices: [locationCodeableConcept] index: 45 locationCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: location, index: 46} quantity: {index: 48} adjudication: mustSupport: true array: true min: 2 index: 49 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} index: 50 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: 51 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 52 amount: {mustSupport: true, index: 53} 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: 54 elements: category: pattern: type: CodeableConcept value: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 55 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'} mustSupport: true index: 56 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: 57 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'} index: 58 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: 59 elements: category: pattern: type: CodeableConcept value: coding: - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 60 required: [location, serviced, locationCodeableConcept] type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBProfessionalAndNonClinicianClaimType'} index: 1 total: index: 62 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} mustSupport: true index: 63 amount: {index: 64} 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: 65 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 66 billablePeriod: {index: 3} subType: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBProfessionalAndNonClinicianClaimSubType'} 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-Professional-NonClinician 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: 4 elements: role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole'} index: 5 qualification: binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066'} mustSupport: true index: 6 required: [role] package_version: bb-1.2.0 class: profile kind: resource url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit version: 1.2.0 required: [diagnosis, billablePeriod]