{
"description": "Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide.\\nAll EOB instances should be from one of the four concrete EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician",
"_filename": "StructureDefinition-C4BB-ExplanationOfBenefit.json",
"package_name": "hl7.fhir.us.carin-bb",
"date": "2022-11-28T15:16:46+00:00",
"derivation": "constraint",
"publisher": "HL7 Financial Management Working Group",
"fhirVersion": "4.0.1",
"jurisdiction": [ {
"coding": [ {
"code": "US",
"system": "urn:iso:std:iso:3166"
} ]
} ],
"name": "C4BBExplanationOfBenefit",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": true,
"type": "ExplanationOfBenefit",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "C4BB Explanation Of Benefit",
"package_version": "2.0.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.General"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
} ],
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"xpath": "not(exists(f:contained/*/f:meta/f:security))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"xpath": "exists(f:text/h:div)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "warning",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
} ],
"expression": "text.`div`.exists()"
} ],
"path": "ExplanationOfBenefit",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Explanation of Benefit resource",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Event",
"identity": "workflow"
} ],
"alias": [ "EOB" ],
"max": "*",
"id": "ExplanationOfBenefit",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"isModifier": false,
"short": "Logical id of this artifact",
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.id",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.meta.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.meta.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.meta.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.meta.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.versionId",
"min": 0,
"definition": "The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.",
"isModifier": false,
"short": "Version specific identifier",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "ExplanationOfBenefit.meta.versionId",
"comment": "The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.",
"base": {
"max": "1",
"min": 0,
"path": "Meta.versionId"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.lastUpdated",
"min": 1,
"definition": "When the resource last changed - e.g. when the version changed.",
"isModifier": false,
"short": "When the resource version last changed",
"type": [ {
"code": "instant"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.meta.lastUpdated",
"comment": "Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last",
"base": {
"max": "1",
"min": 0,
"path": "Meta.lastUpdated"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.source",
"min": 0,
"definition": "A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.",
"isModifier": false,
"short": "Identifies where the resource comes from",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "ExplanationOfBenefit.meta.source",
"comment": "In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. \n\nThis element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.",
"base": {
"max": "1",
"min": 0,
"path": "Meta.source"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.profile",
"min": 1,
"definition": "A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).",
"isModifier": false,
"short": "Profiles this resource claims to conform to",
"type": [ {
"code": "canonical",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/StructureDefinition" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.meta.profile",
"comment": "meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest. CPCDS data element (190)",
"base": {
"max": "*",
"min": 0,
"path": "Meta.profile"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.security",
"min": 0,
"definition": "Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.",
"isModifier": false,
"short": "Security Labels applied to this resource",
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/security-labels",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SecurityLabels"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "Security Labels from the Healthcare Privacy and Security Classification System."
},
"max": "*",
"id": "ExplanationOfBenefit.meta.security",
"comment": "The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.",
"base": {
"max": "*",
"min": 0,
"path": "Meta.security"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.meta.tag",
"min": 0,
"definition": "Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.",
"isModifier": false,
"short": "Tags applied to this resource",
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/common-tags",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Tags"
} ],
"description": "Codes that represent various types of tags, commonly workflow-related; e.g. \"Needs review by Dr. Jones\"."
},
"max": "*",
"id": "ExplanationOfBenefit.meta.tag",
"comment": "The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.",
"base": {
"max": "*",
"min": 0,
"path": "Meta.tag"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.implicitRules",
"min": 0,
"definition": "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.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "ExplanationOfBenefit.implicitRules",
"comment": "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 it's narrative along with other profiles, value sets, etc.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A human language."
},
"max": "1",
"id": "ExplanationOfBenefit.language",
"comment": "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).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.text",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "ExplanationOfBenefit.text",
"comment": "Contained resources do not have 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.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"isModifier": false,
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "ExplanationOfBenefit.contained",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier",
"requirements": "Allows EOBs to be distinguished and referenced.",
"min": 1,
"definition": "A unique identifier assigned to this explanation of benefit.",
"isModifier": false,
"short": "Business Identifier for the resource",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice based on value pattern",
"discriminator": [ {
"path": "type",
"type": "pattern"
} ]
},
"type": [ {
"code": "Identifier"
} ],
"max": "*",
"id": "ExplanationOfBenefit.identifier",
"comment": "Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.identifier.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.identifier.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.identifier.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.identifier.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.use",
"requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.",
"min": 0,
"definition": "The purpose of this identifier.",
"isModifier": true,
"short": "usual | official | temp | secondary | old (If known)",
"mapping": [ {
"map": "N/A",
"identity": "v2"
}, {
"map": "Role.code or implied by context",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "IdentifierUse"
} ],
"description": "Identifies the purpose for this identifier, if known ."
},
"max": "1",
"id": "ExplanationOfBenefit.identifier.use",
"comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.use"
},
"isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.type",
"requirements": "Allows users to make use of identifiers when the identifier system is not known.",
"min": 0,
"definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.",
"isModifier": false,
"short": "Description of identifier",
"mapping": [ {
"map": "CX.5",
"identity": "v2"
}, {
"map": "Role.code or implied by context",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/identifier-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "IdentifierType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose."
},
"max": "1",
"id": "ExplanationOfBenefit.identifier.type",
"comment": "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.type"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.system",
"requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.",
"min": 0,
"definition": "Establishes the namespace for the value - that is, a URL that describes a set values that are unique.",
"isModifier": false,
"short": "The namespace for the identifier value",
"mapping": [ {
"map": "CX.4 / EI-2-4",
"identity": "v2"
}, {
"map": "II.root or Role.id.root",
"identity": "rim"
}, {
"map": "./IdentifierType",
"identity": "servd"
} ],
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier.system",
"comment": "Identifier.system is always case sensitive.",
"example": [ {
"label": "General",
"valueUri": "http://www.acme.com/identifiers/patient"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Identifier.system"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.value",
"min": 0,
"definition": "The portion of the identifier typically relevant to the user and which is unique within the context of the system.",
"isModifier": false,
"short": "The value that is unique",
"mapping": [ {
"map": "CX.1 / EI.1",
"identity": "v2"
}, {
"map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)",
"identity": "rim"
}, {
"map": "./Value",
"identity": "servd"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier.value",
"comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.",
"example": [ {
"label": "General",
"valueString": "123456"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Identifier.value"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.period",
"min": 0,
"definition": "Time period during which identifier is/was valid for use.",
"isModifier": false,
"short": "Time period when id is/was valid for use",
"mapping": [ {
"map": "CX.7 + CX.8",
"identity": "v2"
}, {
"map": "Role.effectiveTime or implied by context",
"identity": "rim"
}, {
"map": "./StartDate and ./EndDate",
"identity": "servd"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier.period",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.period"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.assigner",
"min": 0,
"definition": "Organization that issued/manages the identifier.",
"isModifier": false,
"short": "Organization that issued id (may be just text)",
"mapping": [ {
"map": "CX.4 / (CX.4,CX.9,CX.10)",
"identity": "v2"
}, {
"map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper",
"identity": "rim"
}, {
"map": "./IdentifierIssuingAuthority",
"identity": "servd"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier.assigner",
"comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.assigner"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier",
"requirements": "Allows EOBs to be distinguished and referenced.",
"min": 1,
"definition": "A unique identifier assigned to this explanation of benefit.",
"isModifier": false,
"short": "Unique Claim Identifier",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": true,
"sliceName": "uniqueclaimid",
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.identifier.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.identifier.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.use",
"requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.",
"min": 0,
"definition": "The purpose of this identifier.",
"isModifier": true,
"short": "usual | official | temp | secondary | old (If known)",
"mapping": [ {
"map": "N/A",
"identity": "v2"
}, {
"map": "Role.code or implied by context",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "IdentifierUse"
} ],
"description": "Identifies the purpose for this identifier, if known ."
},
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.use",
"comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.use"
},
"isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.type",
"requirements": "Allows users to make use of identifiers when the identifier system is not known.",
"min": 1,
"definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.",
"isModifier": false,
"short": "Description of identifier",
"mapping": [ {
"map": "CX.5",
"identity": "v2"
}, {
"map": "Role.code or implied by context",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/identifier-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "IdentifierType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose."
},
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.type",
"comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.",
"patternCodeableConcept": {
"coding": [ {
"code": "uc",
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Identifier.type"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.system",
"requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.",
"min": 0,
"definition": "Establishes the namespace for the value - that is, a URL that describes a set values that are unique.",
"isModifier": false,
"short": "The namespace for the identifier value",
"mapping": [ {
"map": "CX.4 / EI-2-4",
"identity": "v2"
}, {
"map": "II.root or Role.id.root",
"identity": "rim"
}, {
"map": "./IdentifierType",
"identity": "servd"
} ],
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.system",
"comment": "Identifier.system is always case sensitive.",
"example": [ {
"label": "General",
"valueUri": "http://www.acme.com/identifiers/patient"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Identifier.system"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.value",
"min": 1,
"definition": "The portion of the identifier typically relevant to the user and which is unique within the context of the system.",
"isModifier": false,
"short": "Unique Claim Identifier",
"mapping": [ {
"map": "CX.1 / EI.1",
"identity": "v2"
}, {
"map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)",
"identity": "rim"
}, {
"map": "./Value",
"identity": "servd"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.value",
"comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.",
"example": [ {
"label": "General",
"valueString": "123456"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Identifier.value"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.period",
"min": 0,
"definition": "Time period during which identifier is/was valid for use.",
"isModifier": false,
"short": "Time period when id is/was valid for use",
"mapping": [ {
"map": "CX.7 + CX.8",
"identity": "v2"
}, {
"map": "Role.effectiveTime or implied by context",
"identity": "rim"
}, {
"map": "./StartDate and ./EndDate",
"identity": "servd"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.period",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.period"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.identifier.assigner",
"min": 0,
"definition": "Organization that issued/manages the identifier.",
"isModifier": false,
"short": "Organization that issued id (may be just text)",
"mapping": [ {
"map": "CX.4 / (CX.4,CX.9,CX.10)",
"identity": "v2"
}, {
"map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper",
"identity": "rim"
}, {
"map": "./IdentifierIssuingAuthority",
"identity": "servd"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.assigner",
"comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.",
"base": {
"max": "1",
"min": 0,
"path": "Identifier.assigner"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ExplanationOfBenefitStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "ExplanationOfBenefit.status",
"comment": "Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.status"
},
"isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.type",
"requirements": "Claim type determine the general sets of business rules applied for information requirements and adjudication.",
"min": 1,
"definition": "The category of claim, e.g. oral, pharmacy, vision, institutional, professional.",
"isModifier": false,
"short": "Category or discipline",
"mapping": [ {
"map": "Event.code",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type"
},
"max": "1",
"id": "ExplanationOfBenefit.type",
"comment": "Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.type"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.subType",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 0,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode."
},
"max": "1",
"id": "ExplanationOfBenefit.subType",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.subType"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.use",
"requirements": "This element is required to understand the nature of the request for adjudication.",
"min": 1,
"definition": "A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.",
"isModifier": false,
"short": "claim | preauthorization | predetermination",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"patternCode": "claim",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-use|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "Complete, proposed, exploratory, other."
},
"max": "1",
"id": "ExplanationOfBenefit.use",
"comment": "Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.use"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.patient",
"requirements": "The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "The recipient of the products and services",
"mapping": [ {
"map": "Event.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.patient",
"comment": "Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.patient"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.billablePeriod",
"requirements": "A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.",
"min": 1,
"definition": "The period for which charges are being submitted.",
"isModifier": false,
"short": "Relevant time frame for the claim",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Period"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.billablePeriod",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.billablePeriod"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.billablePeriod.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.billablePeriod.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.billablePeriod.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.billablePeriod.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.billablePeriod.start",
"min": 1,
"definition": "The start of the period. The boundary is inclusive.",
"isModifier": false,
"short": "Starting time with inclusive boundary",
"mapping": [ {
"map": "DR.1",
"identity": "v2"
}, {
"map": "./low",
"identity": "rim"
} ],
"type": [ {
"code": "dateTime"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.billablePeriod.start",
"condition": [ "per-1" ],
"comment": "The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)",
"base": {
"max": "1",
"min": 0,
"path": "Period.start"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.billablePeriod.end",
"min": 0,
"definition": "The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.",
"isModifier": false,
"short": "End time with inclusive boundary, if not ongoing",
"mapping": [ {
"map": "DR.2",
"identity": "v2"
}, {
"map": "./high",
"identity": "rim"
} ],
"type": [ {
"code": "dateTime"
} ],
"meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing",
"max": "1",
"id": "ExplanationOfBenefit.billablePeriod.end",
"condition": [ "per-1" ],
"comment": "The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)",
"base": {
"max": "1",
"min": 0,
"path": "Period.end"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"definition": "The date this resource was created.",
"isModifier": false,
"short": "Response creation date",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "ExplanationOfBenefit.created",
"comment": "Date the claim was adjudicated (179)",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.created"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.enterer",
"requirements": "Some jurisdictions require the contact information for personnel completing claims.",
"min": 0,
"definition": "Individual who created the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Author of the claim",
"mapping": [ {
"map": "Event.performer.agent",
"identity": "workflow"
}, {
"map": "FiveWs.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.enterer",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.enterer"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.insurer",
"requirements": "To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.",
"min": 1,
"definition": "The party responsible for authorization, adjudication and reimbursement.",
"isModifier": false,
"short": "Party responsible for reimbursement",
"mapping": [ {
"map": "Event.performer.agent",
"identity": "workflow"
}, {
"map": "FiveWs.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.insurer",
"comment": "Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.insurer"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.provider",
"min": 1,
"definition": "The provider which is responsible for the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Party responsible for the claim",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.provider",
"comment": "The identifier assigned to the Billing Provider. (94)",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.provider"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.priority",
"requirements": "The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.",
"min": 0,
"definition": "The provider-required urgency of processing the request. Typical values include: stat, routine deferred.",
"isModifier": false,
"short": "Desired processing urgency",
"mapping": [ {
"map": "Request.priority",
"identity": "v2"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority"
},
"max": "1",
"id": "ExplanationOfBenefit.priority",
"comment": "If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.priority"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.fundsReserveRequested",
"requirements": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"definition": "A code to indicate whether and for whom funds are to be reserved for future claims.",
"isModifier": false,
"short": "For whom to reserve funds",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "For whom funds are to be reserved: (Patient, Provider, None)."
},
"alias": [ "Fund pre-allocation" ],
"max": "1",
"id": "ExplanationOfBenefit.fundsReserveRequested",
"comment": "This field is only used for preauthorizations.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.fundsReserveRequested"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.fundsReserve",
"requirements": "Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.",
"min": 0,
"definition": "A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.",
"isModifier": false,
"short": "Funds reserved status",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "For whom funds are to be reserved: (Patient, Provider, None)."
},
"max": "1",
"id": "ExplanationOfBenefit.fundsReserve",
"comment": "Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.fundsReserve"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.related",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.",
"isModifier": false,
"short": "Prior or corollary claims",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"max": "*",
"id": "ExplanationOfBenefit.related",
"comment": "If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.related"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.related.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.related.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.related.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.related.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.related.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.related.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.related.claim",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Reference to a related claim.",
"isModifier": false,
"short": "Reference to the related claim",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.related.claim",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.claim"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.related.relationship",
"requirements": "Some insurers need a declaration of the type of relationship.",
"min": 1,
"definition": "A code to convey how the claims are related.",
"isModifier": false,
"short": "How the reference claim is related",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes"
},
"max": "1",
"id": "ExplanationOfBenefit.related.relationship",
"comment": "For example, prior claim or umbrella.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.relationship"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.related.reference",
"requirements": "In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.",
"min": 1,
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains.",
"isModifier": false,
"short": "File or case reference",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.related.reference",
"comment": "For example, Property/Casualty insurer claim number or Workers Compensation case number.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.reference"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.prescription",
"requirements": "Required to authorize the dispensing of controlled substances and devices.",
"min": 0,
"definition": "Prescription to support the dispensing of pharmacy, device or vision products.",
"isModifier": false,
"short": "Prescription authorizing services or products",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.prescription",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.prescription"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.originalPrescription",
"requirements": "Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.",
"min": 0,
"definition": "Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.",
"isModifier": false,
"short": "Original prescription if superceded by fulfiller",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationRequest" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.originalPrescription",
"comment": "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'.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalPrescription"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "EOB-payee-other-type-requires-party",
"human": "Base EOB: if payee type is other, payee party is required",
"source": "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit",
"severity": "error",
"expression": "type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()"
} ],
"path": "ExplanationOfBenefit.payee",
"requirements": "The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.",
"min": 0,
"definition": "The party to be reimbursed for cost of the products and services according to the terms of the policy.",
"isModifier": false,
"short": "Recipient of benefits payable",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payee",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.payee.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.payee.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.payee.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.payee.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.payee.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.payee.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payee.type",
"requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.",
"min": 1,
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"short": "Category of recipient",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType"
},
"max": "1",
"id": "ExplanationOfBenefit.payee.type",
"comment": "Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payee.party",
"requirements": "Need to provide demographics if the payee is not 'subscriber' nor 'provider'.",
"min": 0,
"definition": "Reference to the individual or organization to whom any payment will be made.",
"isModifier": false,
"short": "Recipient reference",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-RelatedPerson" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.payee.party",
"comment": "Recipient reference (121)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.party"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.referral",
"requirements": "Some insurers require proof of referral to pay for services or to pay specialist rates for services.",
"min": 0,
"definition": "A reference to a referral resource.",
"isModifier": false,
"short": "Treatment Referral",
"mapping": [ {
"map": "FiveWs.cause",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.referral",
"comment": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.referral"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.facility",
"requirements": "Insurance adjudication can be dependant on where services were delivered.",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing Facility",
"mapping": [ {
"map": "Event.performer.location",
"identity": "workflow"
}, {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.facility",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.facility"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.claim",
"requirements": "To provide a link to the original adjudication request.",
"min": 0,
"definition": "The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.",
"isModifier": false,
"short": "Claim reference",
"mapping": [ {
"map": "FiveWs.why[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.claim",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claim"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.claimResponse",
"requirements": "To provide a link to the original adjudication response.",
"min": 0,
"definition": "The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.",
"isModifier": false,
"short": "Claim response reference",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.claimResponse",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claimResponse"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.outcome",
"requirements": "To advise the requestor of an overall processing outcome.",
"min": 1,
"definition": "The outcome of the claim, predetermination, or preauthorization processing.",
"isModifier": false,
"short": "queued | complete | error | partial",
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
} ],
"description": "The result of the claim processing."
},
"max": "1",
"id": "ExplanationOfBenefit.outcome",
"comment": "Expected value is complete",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.outcome"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.disposition",
"requirements": "Provided for user display.",
"min": 0,
"definition": "A human readable description of the status of the adjudication.",
"isModifier": false,
"short": "Disposition Message",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "ExplanationOfBenefit.disposition",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.disposition"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.preAuthRef",
"requirements": "On subsequent claims, the insurer may require the provider to quote this value.",
"min": 0,
"definition": "Reference from the Insurer which is used in later communications which refers to this adjudication.",
"isModifier": false,
"short": "Preauthorization reference",
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ExplanationOfBenefit.preAuthRef",
"comment": "This value is only present on preauthorization adjudications.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.preAuthRef"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.preAuthRefPeriod",
"requirements": "On subsequent claims, the insurer may require the provider to quote this value.",
"min": 0,
"definition": "The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.",
"isModifier": false,
"short": "Preauthorization in-effect period",
"type": [ {
"code": "Period"
} ],
"max": "*",
"id": "ExplanationOfBenefit.preAuthRefPeriod",
"comment": "This value is only present on preauthorization adjudications.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.preAuthRefPeriod"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam",
"requirements": "Common to identify the responsible and supporting practitioners.",
"min": 0,
"definition": "The members of the team who provided the products and services.",
"isModifier": false,
"short": "Care Team members",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "ExplanationOfBenefit.careTeam",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.careTeam"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.careTeam.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.careTeam.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.careTeam.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.careTeam.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.careTeam.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.careTeam.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam.sequence",
"requirements": "Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.",
"min": 1,
"definition": "A number to uniquely identify care team entries.",
"isModifier": false,
"short": "Order of care team",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.careTeam.sequence",
"comment": "careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam.provider",
"requirements": "Often a regulatory requirement to specify the responsible provider.",
"min": 1,
"definition": "Member of the team who provided the product or service.",
"isModifier": false,
"short": "Practitioner or organization",
"mapping": [ {
"map": "FiveWs.actor",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.careTeam.provider",
"comment": "The identifier assigned to the care team. (varies depending on the profile)",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.provider"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam.responsible",
"requirements": "When multiple parties are present it is required to distinguish the lead or responsible individual.",
"min": 0,
"definition": "The party who is billing and/or responsible for the claimed products or services.",
"isModifier": false,
"short": "Indicator of the lead practitioner",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "ExplanationOfBenefit.careTeam.responsible",
"comment": "Responsible might not be required when there is only a single provider listed.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.responsible"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam.role",
"requirements": "When multiple parties are present it is required to distinguish the roles performed by each member.",
"min": 0,
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.",
"isModifier": false,
"short": "Function within the team",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-careteamrole",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members."
},
"max": "1",
"id": "ExplanationOfBenefit.careTeam.role",
"comment": "The functional role of a provider on a claim. (165)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.role"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam.qualification",
"requirements": "Need to specify which qualification a provider is delivering the product or service under.",
"min": 0,
"definition": "The qualification of the practitioner which is applicable for this service.",
"isModifier": false,
"short": "Practitioner credential or specialization",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/provider-qualification",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications."
},
"max": "1",
"id": "ExplanationOfBenefit.careTeam.qualification",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.qualification"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.",
"isModifier": false,
"short": "Supporting information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"max": "*",
"id": "ExplanationOfBenefit.supportingInfo",
"comment": "Defines data elements not available in the base EOB resource",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.supportingInfo"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.supportingInfo.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.supportingInfo.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.supportingInfo.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.supportingInfo.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.supportingInfo.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.sequence",
"requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify supporting information entries.",
"isModifier": false,
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.sequence",
"comment": "Client app implementations should look-up supportingInfo elements based on category values instead of sequence values",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.supportingInfo.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.category",
"requirements": "Required to group or associate information items with common characteristics. For example: admission information or prior treatments.",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"isModifier": false,
"short": "Classification of the supplied information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType"
},
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.category",
"comment": "This may contain a category for the local bill type codes.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.supportingInfo.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.code",
"requirements": "Required to identify the kind of additional information.",
"min": 0,
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.",
"isModifier": false,
"short": "Type of information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-exception",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
} ],
"description": "The valuset used for additional information codes."
},
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.code",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.supportingInfo.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.timing[x]",
"min": 0,
"definition": "The date when or period to which this information refers.",
"isModifier": false,
"short": "When it occurred",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.timing[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.supportingInfo.timing[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.value[x]",
"requirements": "To convey the data content to be provided when the information is more than a simple code or period.",
"min": 0,
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"isModifier": false,
"short": "Data to be provided",
"type": [ {
"code": "boolean"
}, {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.value[x]",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.supportingInfo.value[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.supportingInfo.reason",
"requirements": "Needed when the supporting information has both a date and amount/value and requires explanation.",
"min": 0,
"definition": "Provides the reason in the situation where a reason code is required in addition to the content.",
"isModifier": false,
"short": "Explanation for the information",
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/missing-tooth-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth."
},
"max": "1",
"id": "ExplanationOfBenefit.supportingInfo.reason",
"comment": "For example: the reason for the additional stay, or why a tooth is missing.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.supportingInfo.reason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis",
"requirements": "Required for the adjudication by provided context for the services and product listed.",
"min": 0,
"definition": "Information about diagnoses relevant to the claim items.",
"isModifier": false,
"short": "Pertinent diagnosis information",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "ExplanationOfBenefit.diagnosis",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.diagnosis.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.diagnosis.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.diagnosis.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.diagnosis.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.diagnosis.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis.sequence",
"requirements": "Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify diagnosis entries.",
"isModifier": false,
"short": "Diagnosis instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.sequence",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.diagnosis.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"requirements": "Provides health context for the evaluation of the products and/or services.",
"min": 1,
"definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"isModifier": false,
"short": "Nature of illness or problem",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes."
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"isModifier": false,
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosistype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
} ],
"description": "The type of the diagnosis: admitting, principal, discharge."
},
"max": "*",
"id": "ExplanationOfBenefit.diagnosis.type",
"comment": "For example: admitting, primary, secondary, discharge.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis.onAdmission",
"requirements": "Many systems need to understand for adjudication if the diagnosis was present a time of admission.",
"min": 0,
"definition": "Indication of whether the diagnosis was present on admission to a facility.",
"isModifier": false,
"short": "Present on admission",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisOnAdmission"
} ],
"description": "Present on admission."
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.onAdmission",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.onAdmission"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis.packageCode",
"requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis."
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.packageCode",
"comment": "For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.packageCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure",
"requirements": "The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.",
"min": 0,
"definition": "Procedures performed on the patient relevant to the billing items with the claim.",
"isModifier": false,
"short": "Clinical procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"id": "ExplanationOfBenefit.procedure",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.procedure.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.procedure.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.procedure.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.procedure.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.procedure.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure.sequence",
"requirements": "Necessary to provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify procedure entries.",
"isModifier": false,
"short": "Procedure instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.sequence",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.procedure.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"isModifier": false,
"short": "Category of Procedure",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-procedure-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureType"
} ],
"description": "Example procedure type codes."
},
"max": "*",
"id": "ExplanationOfBenefit.procedure.type",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure.date",
"requirements": "Required for auditing purposes.",
"min": 0,
"definition": "Date and optionally time the procedure was performed.",
"isModifier": false,
"short": "When the procedure was performed",
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.date",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.date"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"requirements": "This identifies the actual clinical procedure.",
"min": 1,
"definition": "The code or reference to a Procedure resource which identifies the clinical intervention performed.",
"isModifier": false,
"short": "Specific clinical procedure",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10-procedures",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "ICD10 Procedure codes."
},
"max": "1",
"id": "ExplanationOfBenefit.procedure.procedure[x]",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.procedure.procedure[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.procedure.udi",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure.udi"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.precedence",
"requirements": "Needed to coordinate between multiple EOBs for the same suite of services.",
"min": 0,
"definition": "This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.",
"isModifier": false,
"short": "Precedence (primary, secondary, etc.)",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.precedence",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.precedence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "EOB-insurance-focal",
"human": "EOB.insurance: at most one with focal = true",
"source": "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit",
"severity": "error",
"expression": "insurance.select (focal = true).count() < 2"
} ],
"path": "ExplanationOfBenefit.insurance",
"requirements": "At least one insurer is required for a claim to be a claim.",
"min": 1,
"definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"isModifier": false,
"short": "Patient insurance information",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "ExplanationOfBenefit.insurance",
"comment": "Identity of the payers responsible for the claim. (2, 141). 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. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'",
"base": {
"max": "*",
"min": 1,
"path": "ExplanationOfBenefit.insurance"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.insurance.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.insurance.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.insurance.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.insurance.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.insurance.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.insurance.focal",
"requirements": "To identify which coverage in the list is being used to adjudicate this claim.",
"min": 1,
"definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.",
"isModifier": false,
"short": "Coverage to be used for adjudication",
"type": [ {
"code": "boolean"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.insurance.focal",
"comment": "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. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.insurance.focal"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage" ]
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.insurance.coverage",
"comment": "Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier]",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.insurance.coverage"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.insurance.preAuthRef",
"requirements": "Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Prior authorization reference number",
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ExplanationOfBenefit.insurance.preAuthRef",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.insurance.preAuthRef"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.accident",
"requirements": "When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.",
"min": 0,
"definition": "Details of a accident which resulted in injuries which required the products and services listed in the claim.",
"isModifier": false,
"short": "Details of the event",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.accident.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.accident.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.accident.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.accident.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.accident.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.accident.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.accident.date",
"requirements": "Required for audit purposes and adjudication.",
"min": 0,
"definition": "Date of an accident event related to the products and services contained in the claim.",
"isModifier": false,
"short": "When the incident occurred",
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident.date",
"comment": "The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident.date"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.",
"isModifier": false,
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActIncidentCode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc."
},
"max": "1",
"id": "ExplanationOfBenefit.accident.type",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.accident.location[x]",
"requirements": "Required for audit purposes and determination of applicable insurance liability.",
"min": 0,
"definition": "The physical location of the accident event.",
"isModifier": false,
"short": "Where the event occurred",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident.location[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item",
"requirements": "The items to be processed for adjudication.",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.item.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.item.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.sequence",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.",
"min": 1,
"definition": "A number to uniquely identify item entries.",
"isModifier": false,
"short": "Item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": true,
"max": "1",
"id": "ExplanationOfBenefit.item.sequence",
"comment": "Line identification number that represents the number assigned in a source system for identification and processing. (36)",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.careTeamSequence",
"requirements": "Need to identify the individuals and their roles in the provision of the product or service.",
"min": 0,
"definition": "Care team members related to this service or product.",
"isModifier": false,
"short": "Applicable care team members",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.careTeamSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.careTeamSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.diagnosisSequence",
"requirements": "Need to related the product or service to the associated diagnoses.",
"min": 0,
"definition": "Diagnoses applicable for this service or product.",
"isModifier": false,
"short": "Applicable diagnoses",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.diagnosisSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.diagnosisSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.procedureSequence",
"requirements": "Need to provide any listed specific procedures to support the product or service being claimed.",
"min": 0,
"definition": "Procedures applicable for this service or product.",
"isModifier": false,
"short": "Applicable procedures",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.procedureSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.procedureSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.informationSequence",
"requirements": "Need to reference the supporting information items that relate directly to this product or service.",
"min": 0,
"definition": "Exceptions, special conditions and supporting information applicable for this service or product.",
"isModifier": false,
"short": "Applicable exception and supporting information",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.informationSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.informationSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ExplanationOfBenefit.item.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision, oral-basic etc."
},
"max": "1",
"id": "ExplanationOfBenefit.item.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.item.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Product or service billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.item.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ExplanationOfBenefit.item.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.programCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"isModifier": false,
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.serviced[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"isModifier": false,
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place where the service is rendered."
},
"max": "1",
"id": "ExplanationOfBenefit.item.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.location[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.udi",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.udi"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.bodySite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"isModifier": false,
"short": "Anatomical location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch."
},
"max": "1",
"id": "ExplanationOfBenefit.item.bodySite",
"comment": "For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.bodySite"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"isModifier": false,
"short": "Anatomical sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations."
},
"max": "*",
"id": "ExplanationOfBenefit.item.subSite",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.subSite"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.encounter",
"requirements": "Used in some jurisdictions to link clinical events to claim items.",
"min": 0,
"definition": "A billed item may include goods or services provided in multiple encounters.",
"isModifier": false,
"short": "Encounters related to this billed item",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.encounter",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.encounter"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": true,
"max": "*",
"id": "ExplanationOfBenefit.item.noteNumber",
"comment": "References number of the associated processNote entered",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication",
"requirements": "The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.adjudication.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.adjudication.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.item.adjudication.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication.category",
"requirements": "Needed to enable understanding of the context of the other information in the adjudication.",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.category",
"comment": "For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.adjudication.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication.reason",
"requirements": "To support understanding of variance from adjudication expectations.",
"min": 0,
"definition": "A code supporting the understanding of the adjudication result and explaining variance from expected amount.",
"isModifier": false,
"short": "Explanation of adjudication outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
} ],
"description": "Adjudication reason codes."
},
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.reason",
"comment": "For example, may indicate that the funds for this benefit type have been exhausted.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.reason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication.amount",
"requirements": "Most adjuciation categories convey a monetary amount.",
"min": 0,
"definition": "Monetary amount associated with the category.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.amount",
"comment": "For example, amount submitted, eligible amount, co-payment, and benefit payable.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.amount"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication.value",
"requirements": "Some adjudication categories convey a percentage or a fixed value.",
"min": 0,
"definition": "A non-monetary value associated with the category. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitary value",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.value",
"comment": "For example: eligible percentage or co-payment percentage.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.value"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail",
"min": 0,
"definition": "Second-tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.detail.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.detail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.sequence",
"requirements": "The items to be processed for adjudication.",
"min": 1,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.sequence",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision, oral-basic etc."
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.category",
"comment": "Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.programCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.udi",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.udi"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Detail level adjudication details",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.item.detail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail",
"min": 0,
"definition": "Third-tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"requirements": "The items to be processed for adjudication.",
"min": 1,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision, oral-basic etc."
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.udi",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.udi"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Subdetail level adjudication details",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem",
"requirements": "Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.",
"min": 0,
"definition": "The first-tier service adjudications for payor added product or service lines.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "740;600"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.itemSequence",
"requirements": "Provides references to the claim items.",
"min": 0,
"definition": "Claim items which this service line is intended to replace.",
"isModifier": false,
"short": "Item sequence number",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.itemSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.itemSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detailSequence",
"requirements": "Provides references to the claim details within the claim item.",
"min": 0,
"definition": "The sequence number of the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Detail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detailSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.subDetailSequence",
"requirements": "Provides references to the claim sub-details within the claim detail.",
"min": 0,
"definition": "The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Subdetail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.subDetailSequence",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.subDetailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.provider",
"requirements": "Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.",
"min": 0,
"definition": "The providers who are authorized for the services rendered to the patient.",
"isModifier": false,
"short": "Authorized providers",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.provider",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.provider"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.addItem.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.programCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"isModifier": false,
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.serviced[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"isModifier": false,
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place where the service is rendered."
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.location[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.bodySite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"isModifier": false,
"short": "Anatomical location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch."
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.bodySite",
"comment": "For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.bodySite"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"isModifier": false,
"short": "Anatomical sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations."
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.subSite",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.subSite"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items adjudication",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.addItem.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail",
"min": 0,
"definition": "The second-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "740;600"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.detail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.detail.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.detail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.addItem.detail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items adjudication",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail",
"min": 0,
"definition": "The third-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "740;600"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetailSubDetail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.detail.subDetail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items adjudication",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.adjudication",
"requirements": "Some insurers will receive line-items but provide the adjudication only at a summary or header-level.",
"min": 0,
"definition": "The adjudication results which are presented at the header level rather than at the line-item or add-item levels.",
"isModifier": false,
"short": "Header-level adjudication",
"contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication",
"max": "*",
"id": "ExplanationOfBenefit.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.total",
"requirements": "To provide the requestor with financial totals by category for the adjudication.",
"min": 1,
"definition": "Categorized monetary totals for the adjudication.",
"isModifier": false,
"short": "Adjudication totals",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "'360;620"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Total"
} ],
"max": "*",
"id": "ExplanationOfBenefit.total",
"comment": "Totals for amounts submitted, co-pays, benefits payable etc.",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.total"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.total.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.total.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.total.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.total.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.total.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.total.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.total.category",
"requirements": "Needed to convey the type of total provided.",
"min": 1,
"definition": "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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ExplanationOfBenefit.total.category",
"comment": "For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.total.category"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.total.amount",
"requirements": "Needed to convey the total monetary amount.",
"min": 1,
"definition": "Monetary total amount associated with the category.",
"isModifier": false,
"short": "Financial total for the category",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.total.amount",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.total.amount"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment",
"requirements": "Needed to convey references to the financial instrument that has been used if payment has been made.",
"min": 0,
"definition": "Payment details for the adjudication of the claim.",
"isModifier": false,
"short": "Payment Details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "360;650"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.payment.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.payment.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.payment.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.payment.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.payment.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.payment.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.type",
"requirements": "To advise the requestor when the insurer believes all payments to have been completed.",
"min": 0,
"definition": "Whether this represents partial or complete payment of the benefits payable.",
"isModifier": false,
"short": "Partial or complete payment",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode"
},
"max": "1",
"id": "ExplanationOfBenefit.payment.type",
"comment": "Indicates whether the claim was paid or denied. (91)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.adjustment",
"requirements": "To advise the requestor of adjustments applied to the payment.",
"min": 0,
"definition": "Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.",
"isModifier": false,
"short": "Payment adjustment for non-claim issues",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment.adjustment",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustment"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.adjustmentReason",
"requirements": "Needed to clarify the monetary adjustment.",
"min": 0,
"definition": "Reason for the payment adjustment.",
"isModifier": false,
"short": "Explanation for the variance",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
} ],
"description": "Payment Adjustment reason codes."
},
"max": "1",
"id": "ExplanationOfBenefit.payment.adjustmentReason",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustmentReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.date",
"requirements": "To advise the payee when payment can be expected.",
"min": 0,
"definition": "Estimated date the payment will be issued or the actual issue date of payment.",
"isModifier": false,
"short": "Expected date of payment",
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment.date",
"comment": "The date the claim was paid. (107)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.date"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.amount",
"requirements": "Needed to provide the actual payment amount.",
"min": 0,
"definition": "Benefits payable less any payment adjustment.",
"isModifier": false,
"short": "Payable amount after adjustment",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment.amount",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.amount"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment.identifier",
"requirements": "Enable the receiver to reconcile when payment received.",
"min": 0,
"definition": "Issuer's unique identifier for the payment instrument.",
"isModifier": false,
"short": "Business identifier for the payment",
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment.identifier",
"comment": "For example: EFT number or check number.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.identifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.formCode",
"requirements": "Needed to specify the specific form used for producing output for this response.",
"min": 0,
"definition": "A code for the form to be used for printing the content.",
"isModifier": false,
"short": "Printed form identifier",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/forms",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The forms codes."
},
"max": "1",
"id": "ExplanationOfBenefit.formCode",
"comment": "May be needed to identify specific jurisdictional forms.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.formCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.form",
"requirements": "Needed to include the specific form used for producing output for this response.",
"min": 0,
"definition": "The actual form, by reference or inclusion, for printing the content or an EOB.",
"isModifier": false,
"short": "Printed reference or actual form",
"type": [ {
"code": "Attachment"
} ],
"max": "1",
"id": "ExplanationOfBenefit.form",
"comment": "Needed to permit insurers to include the actual form.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.form"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote",
"requirements": "Provides the insurer specific textual explanations associated with the processing.",
"min": 0,
"definition": "A note that describes or explains adjudication results in a human readable form.",
"isModifier": false,
"short": "Note concerning adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"max": "*",
"id": "ExplanationOfBenefit.processNote",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.processNote"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.processNote.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.processNote.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.processNote.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.processNote.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.processNote.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.processNote.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote.number",
"requirements": "Necessary to provide a mechanism to link from adjudications.",
"min": 0,
"definition": "A number to uniquely identify a note entry.",
"isModifier": false,
"short": "Note instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "ExplanationOfBenefit.processNote.number",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.number"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote.type",
"requirements": "To convey the expectation for when the text is used.",
"min": 0,
"definition": "The business purpose of the note text.",
"isModifier": false,
"short": "display | print | printoper",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/note-type|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The presentation types of notes."
},
"max": "1",
"id": "ExplanationOfBenefit.processNote.type",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote.text",
"requirements": "Required to provide human readable explanation.",
"min": 0,
"definition": "The explanation or description associated with the processing.",
"isModifier": false,
"short": "Note explanatory text",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "ExplanationOfBenefit.processNote.text",
"comment": "Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181)",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote.language",
"requirements": "Note text may vary from the resource defined language.",
"min": 0,
"definition": "A code to define the language used in the text of the note.",
"isModifier": false,
"short": "Language of the text",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A human language."
},
"max": "1",
"id": "ExplanationOfBenefit.processNote.language",
"comment": "Only required if the language is different from the resource language.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.language"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitPeriod",
"requirements": "Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.",
"min": 0,
"definition": "The term of the benefits documented in this response.",
"isModifier": false,
"short": "When the benefits are applicable",
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitPeriod",
"comment": "Not applicable when use=claim.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitPeriod"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance",
"min": 0,
"definition": "Balance by Benefit Category.",
"isModifier": false,
"short": "Balance by Benefit Category",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
} ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.benefitBalance.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.benefitBalance.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.category",
"requirements": "Needed to convey the category of service or product for which eligibility is sought.",
"min": 1,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision, oral-basic etc."
},
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.excluded",
"requirements": "Needed to identify items that are specifically excluded from the coverage.",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Excluded from the plan",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.excluded",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.excluded"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.name",
"requirements": "Required to align with other plan names.",
"min": 0,
"definition": "A short name or tag for the benefit.",
"isModifier": false,
"short": "Short name for the benefit",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.name",
"comment": "For example: MED01, or DENT2.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.name"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.description",
"requirements": "Needed for human readable reference.",
"min": 0,
"definition": "A richer description of the benefit or services covered.",
"isModifier": false,
"short": "Description of the benefit or services covered",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.description",
"comment": "For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.description"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.network",
"requirements": "Needed as in or out of network providers are treated differently under the coverage.",
"min": 0,
"definition": "Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.",
"isModifier": false,
"short": "In or out of network",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/benefit-network",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
} ],
"description": "Code to classify in or out of network services."
},
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.network",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.network"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.unit",
"requirements": "Needed for the understanding of the benefits.",
"min": 0,
"definition": "Indicates if the benefits apply to an individual or to the family.",
"isModifier": false,
"short": "Individual or family",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/benefit-unit",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
} ],
"description": "Unit covered/serviced - individual or family."
},
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.unit",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.unit"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.term",
"requirements": "Needed for the understanding of the benefits.",
"min": 0,
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.",
"isModifier": false,
"short": "Annual or lifetime",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/benefit-term",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
} ],
"description": "Coverage unit - annual, lifetime."
},
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.term",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.term"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial",
"min": 0,
"definition": "Benefits Used to date.",
"isModifier": false,
"short": "Benefit Summary",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
} ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.financial",
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.financial.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial.extension",
"min": 0,
"definition": "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 manageable, 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.financial.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "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 manageable, 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).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"requirements": "Needed to convey the nature of the benefit.",
"min": 1,
"definition": "Classification of benefit being provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/benefit-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
} ],
"description": "Deductable, visits, co-pay, etc."
},
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.financial.type",
"comment": "For example: deductible, visits, benefit amount.",
"base": {
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.financial.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"requirements": "Needed to convey the benefits offered under the coverage.",
"min": 0,
"definition": "The quantity of the benefit which is permitted under the coverage.",
"isModifier": false,
"short": "Benefits allowed",
"type": [ {
"code": "unsignedInt"
}, {
"code": "string"
}, {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"requirements": "Needed to convey the benefits consumed to date.",
"min": 0,
"definition": "The quantity of the benefit which have been consumed to date.",
"isModifier": false,
"short": "Benefits used",
"type": [ {
"code": "unsignedInt"
}, {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]"
},
"isSummary": false
} ]
},
"status": "active",
"id": "8bd6cf09-264d-4064-84e7-e637cce3f811",
"kind": "resource",
"url": "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit",
"version": "2.0.0",
"differential": {
"element": [ {
"id": "ExplanationOfBenefit",
"path": "ExplanationOfBenefit"
}, {
"id": "ExplanationOfBenefit.meta",
"min": 1,
"path": "ExplanationOfBenefit.meta",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.meta.lastUpdated",
"min": 1,
"path": "ExplanationOfBenefit.meta.lastUpdated",
"comment": "Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.meta.profile",
"min": 1,
"path": "ExplanationOfBenefit.meta.profile",
"comment": "meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest. CPCDS data element (190)"
}, {
"id": "ExplanationOfBenefit.identifier",
"min": 1,
"path": "ExplanationOfBenefit.identifier",
"comment": "Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice based on value pattern",
"discriminator": [ {
"path": "type",
"type": "pattern"
} ]
}
}, {
"id": "ExplanationOfBenefit.identifier.type",
"path": "ExplanationOfBenefit.identifier.type",
"comment": "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)"
}, {
"id": "ExplanationOfBenefit.identifier:uniqueclaimid",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.identifier",
"short": "Unique Claim Identifier",
"sliceName": "uniqueclaimid",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.type",
"min": 1,
"path": "ExplanationOfBenefit.identifier.type",
"patternCodeableConcept": {
"coding": [ {
"code": "uc",
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
} ]
}
}, {
"id": "ExplanationOfBenefit.identifier:uniqueclaimid.value",
"min": 1,
"path": "ExplanationOfBenefit.identifier.value",
"short": "Unique Claim Identifier",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.status",
"path": "ExplanationOfBenefit.status",
"comment": "Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.type",
"path": "ExplanationOfBenefit.type",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type"
},
"comment": "Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.use",
"path": "ExplanationOfBenefit.use",
"comment": "Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations",
"mustSupport": true,
"patternCode": "claim"
}, {
"id": "ExplanationOfBenefit.patient",
"path": "ExplanationOfBenefit.patient",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient" ]
} ],
"comment": "Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.billablePeriod",
"min": 1,
"path": "ExplanationOfBenefit.billablePeriod",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.billablePeriod.start",
"min": 1,
"path": "ExplanationOfBenefit.billablePeriod.start",
"comment": "The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.billablePeriod.end",
"path": "ExplanationOfBenefit.billablePeriod.end",
"comment": "The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)"
}, {
"id": "ExplanationOfBenefit.created",
"path": "ExplanationOfBenefit.created",
"comment": "Date the claim was adjudicated (179)"
}, {
"id": "ExplanationOfBenefit.insurer",
"path": "ExplanationOfBenefit.insurer",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization" ]
} ],
"comment": "Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.provider",
"path": "ExplanationOfBenefit.provider",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner" ]
} ],
"comment": "The identifier assigned to the Billing Provider. (94)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.priority",
"path": "ExplanationOfBenefit.priority",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority"
}
}, {
"id": "ExplanationOfBenefit.related",
"path": "ExplanationOfBenefit.related",
"comment": "If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.related.relationship",
"min": 1,
"path": "ExplanationOfBenefit.related.relationship",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes"
},
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.related.reference",
"min": 1,
"path": "ExplanationOfBenefit.related.reference",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payee",
"path": "ExplanationOfBenefit.payee",
"constraint": [ {
"key": "EOB-payee-other-type-requires-party",
"human": "Base EOB: if payee type is other, payee party is required",
"source": "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit",
"severity": "error",
"expression": "type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()"
} ],
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payee.type",
"min": 1,
"path": "ExplanationOfBenefit.payee.type",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType"
},
"comment": "Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payee.party",
"path": "ExplanationOfBenefit.payee.party",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-RelatedPerson" ]
} ],
"comment": "Recipient reference (121)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.outcome",
"path": "ExplanationOfBenefit.outcome",
"comment": "Expected value is complete",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.careTeam",
"path": "ExplanationOfBenefit.careTeam",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.careTeam.sequence",
"path": "ExplanationOfBenefit.careTeam.sequence",
"comment": "careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values"
}, {
"id": "ExplanationOfBenefit.careTeam.provider",
"path": "ExplanationOfBenefit.careTeam.provider",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization", "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner" ]
} ],
"comment": "The identifier assigned to the care team. (varies depending on the profile)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.careTeam.role",
"path": "ExplanationOfBenefit.careTeam.role",
"comment": "The functional role of a provider on a claim. (165)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.supportingInfo",
"path": "ExplanationOfBenefit.supportingInfo",
"comment": "Defines data elements not available in the base EOB resource",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.supportingInfo.sequence",
"path": "ExplanationOfBenefit.supportingInfo.sequence",
"comment": "Client app implementations should look-up supportingInfo elements based on category values instead of sequence values"
}, {
"id": "ExplanationOfBenefit.supportingInfo.category",
"path": "ExplanationOfBenefit.supportingInfo.category",
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType"
}
}, {
"id": "ExplanationOfBenefit.insurance",
"path": "ExplanationOfBenefit.insurance",
"comment": "Identity of the payers responsible for the claim. (2, 141). 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. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'",
"constraint": [ {
"key": "EOB-insurance-focal",
"human": "EOB.insurance: at most one with focal = true",
"source": "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit",
"severity": "error",
"expression": "insurance.select (focal = true).count() < 2"
} ],
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.insurance.focal",
"path": "ExplanationOfBenefit.insurance.focal",
"comment": "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. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.insurance.coverage",
"path": "ExplanationOfBenefit.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage" ]
} ],
"comment": "Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier]",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.item",
"min": 1,
"path": "ExplanationOfBenefit.item",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.item.sequence",
"path": "ExplanationOfBenefit.item.sequence",
"comment": "Line identification number that represents the number assigned in a source system for identification and processing. (36)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.item.noteNumber",
"path": "ExplanationOfBenefit.item.noteNumber",
"comment": "References number of the associated processNote entered",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.item.adjudication.category",
"path": "ExplanationOfBenefit.item.adjudication.category",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.total",
"min": 1,
"path": "ExplanationOfBenefit.total",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payment",
"path": "ExplanationOfBenefit.payment",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payment.type",
"path": "ExplanationOfBenefit.payment.type",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode"
},
"comment": "Indicates whether the claim was paid or denied. (91)",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.payment.date",
"path": "ExplanationOfBenefit.payment.date",
"comment": "The date the claim was paid. (107)"
}, {
"id": "ExplanationOfBenefit.processNote",
"path": "ExplanationOfBenefit.processNote",
"mustSupport": true
}, {
"id": "ExplanationOfBenefit.processNote.text",
"path": "ExplanationOfBenefit.processNote.text",
"comment": "Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181)"
} ]
},
"contact": [ {
"name": "HL7 Financial Management Working Group",
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm",
"system": "url"
}, {
"value": "fm@lists.HL7.org",
"system": "email"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit"
}