description: The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay.\nThe claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human\nServices. package_name: hl7.fhir.us.carin-bb derivation: constraint name: C4BBExplanationOfBenefitInpatientInstitutional type: ExplanationOfBenefit elements: processNote: elements: text: {mustSupport: true, index: 96} diagnosis: mustSupport: true index: 51 elements: sequence: {index: 52} diagnosis: mustSupport: true choices: [diagnosisCodeableConcept] index: 54 diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 55} type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType'} mustSupport: true index: 56 onAdmission: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission'} mustSupport: true index: 57 required: [type] meta: elements: profile: pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.2.0'} index: 0 slicing: slices: supportedProfile: match: {} schema: pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.2.0'} index: 0 adjudication: type: BackboneElement mustSupport: true index: 81 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} mustSupport: true index: 82 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: Claim level adjudication type and amount mustSupport: true array: true index: 83 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 84 amount: {index: 85} 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 array: true index: 86 elements: category: pattern: type: CodeableConcept value: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 87 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'} mustSupport: true index: 88 required: [reason] supportingInfo: array: true min: 2 index: 10 slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: category, type: pattern} min: 2 slices: discharge-status: match: category: coding: - {code: discharge-status, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Discharge status mustSupport: true index: 33 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: discharge-status, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 34 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus'} mustSupport: true index: 35 required: [code] pointoforigin: match: category: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Point of origin for admission mustSupport: true index: 27 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 28 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit'} mustSupport: true index: 29 required: [code] typeofbill: match: category: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Type of bill mustSupport: true index: 24 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 25 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill'} mustSupport: true index: 26 required: [code] drg: match: category: coding: - {code: drg, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Diagnosis Related Group mustSupport: true index: 36 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: drg, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 37 code: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG'} mustSupport: true index: 38 required: [code] admtype: match: category: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Admission type mustSupport: true index: 30 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 31 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit'} mustSupport: true index: 32 required: [code] 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: 11 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: billingnetworkcontractingstatus, 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] admissionperiod: match: category: coding: - {code: admissionperiod, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Admission Period mustSupport: true _required: true index: 14 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: admissionperiod, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 15 timing: choices: [] index: 17 timingPeriod: {type: Period, mustSupport: true, index: 18} required: [timingPeriod, timing] clmrecvddate: match: category: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Claim received date mustSupport: true index: 19 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 20 timing: mustSupport: true choices: [timingDate] index: 22 timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 23} 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 _required: true index: 49 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'} index: 50 medicalrecordnumber: match: category: coding: - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Medical record number mustSupport: true index: 39 elements: category: pattern: type: CodeableConcept value: coding: - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 40 value: choices: [] index: 42 valueString: {type: string, mustSupport: true, index: 43} 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: 44 elements: category: pattern: type: CodeableConcept value: coding: - {code: patientaccountnumber, 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] payment: elements: date: {mustSupport: true, index: 95} item: constraint: adjudication-has-amount-type-slice: {human: 'If Adjudication is present, it must have at least one adjudicationamounttype slice', source: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional', severity: error, expression: '(adjudication.exists().not() or adjudication.where(category.memberOf(''http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'')).exists())'} index: 65 elements: revenue: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes'} mustSupport: true index: 66 productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes'} mustSupport: true index: 67 modifier: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers'} mustSupport: true index: 68 quantity: {mustSupport: true, index: 69} adjudication: mustSupport: true index: 70 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} index: 71 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: Line level adjudication type and amount mustSupport: true array: true index: 72 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 73 amount: {mustSupport: true, index: 74} 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 array: true index: 75 elements: category: pattern: type: CodeableConcept value: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 76 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'} mustSupport: true index: 77 required: [reason] 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: 78 elements: category: pattern: type: CodeableConcept value: coding: - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 79 value: {mustSupport: true, index: 80} required: [value] required: [revenue] type: pattern: type: CodeableConcept value: coding: - {code: institutional, system: 'http://terminology.hl7.org/CodeSystem/claim-type'} index: 1 created: {mustSupport: true, index: 6} procedure: mustSupport: true index: 58 elements: sequence: {index: 59} type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType'} mustSupport: true index: 60 date: {mustSupport: true, index: 61} procedure: mustSupport: true choices: [procedureCodeableConcept] index: 63 procedureCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: procedure, index: 64} required: [type] total: index: 89 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator'} mustSupport: true index: 90 amount: {index: 91} 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: 92 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 93 amount: {mustSupport: true, index: 94} billablePeriod: index: 3 elements: start: {mustSupport: true, index: 4} end: {mustSupport: true, index: 5} subType: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType'} mustSupport: true pattern: type: CodeableConcept value: coding: - {code: inpatient, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType'} index: 2 provider: type: Reference refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization'] index: 7 careTeam: constraint: EOB-inst-careTeam-practitioner: human: 'Institutional EOB: Careteam roles refer to a practitioner' source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional severity: error expression: |- ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) ) EOB-inst-careTeam-organization: human: 'Institutional EOB: Careteam roles refer to an organization' source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional severity: error expression: |- ( role.where(coding.where(code in ('performing' )).exists()).exists() implies role.where(coding.where(code in ('performing' )).exists()).exists().provider.all(resolve() is Organization) ) index: 8 elements: role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole'} index: 9 required: [role] package_version: 1.2.0 class: profile kind: resource url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit version: 1.2.0 required: [diagnosis, billablePeriod, subType]