description: The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. \nThe claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human \nServices.
package_name: hl7.fhir.us.carin
derivation: constraint
name: C4BBExplanationOfBenefitInpatientInstitutional
type: ExplanationOfBenefit
elements:
  processNote:
    elements:
      text: {mustSupport: true, index: 95}
  diagnosis:
    mustSupport: true
    index: 49
    elements:
      sequence: {index: 50}
      diagnosis:
        mustSupport: true
        choices: [diagnosisCodeableConcept]
        index: 52
      diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 53}
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType'}
        mustSupport: true
        index: 54
      onAdmission:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission'}
        mustSupport: true
        index: 55
    required: [type]
  meta:
    elements:
      profile:
        pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.1.0'}
        index: 0
        slicing:
          slices:
            supportedProfile:
              match: {}
              schema:
                pattern: {type: Canonical, value: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.1.0'}
                index: 0
  adjudication:
    type: BackboneElement
    constraint:
      adjudication-has-amount-type-slice: {human: 'If Adjudication is present, it must have at least one adjudicationamounttype slice', source: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional', severity: error, expression: '(exists() implies where(category.memberOf(''http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'')).exists())'}
    mustSupport: true
    index: 78
    elements:
      category:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'}
        mustSupport: true
        index: 79
    slicing:
      rules: closed
      ordered: false
      description: Slice based on value pattern
      discriminator:
      - {path: category, type: pattern}
      min: null
      slices:
        adjudicationamounttype:
          match: {category: null}
          schema:
            mustSupport: true
            array: true
            index: 80
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'}
                index: 81
              amount: {index: 82}
            required: [amount]
        denialreason:
          match:
            category:
              coding:
              - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
          schema:
            mustSupport: true
            array: true
            index: 83
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
                index: 84
              reason:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'}
                mustSupport: true
                index: 85
            required: [reason]
  supportingInfo:
    index: 10
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: category, type: pattern}
      min: 1
      slices:
        discharge-status:
          match:
            category:
              coding:
              - {code: discharge-status, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 33
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: discharge-status, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 34
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus'}
                mustSupport: true
                index: 35
            required: [code]
        pointoforigin:
          match:
            category:
              coding:
              - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 27
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 28
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit'}
                mustSupport: true
                index: 29
            required: [code]
        typeofbill:
          match:
            category:
              coding:
              - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 24
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 25
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill'}
                mustSupport: true
                index: 26
            required: [code]
        drg:
          match:
            category:
              coding:
              - {code: drg, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 36
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: drg, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 37
              code:
                binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG'}
                mustSupport: true
                index: 38
            required: [code]
        admtype:
          match:
            category:
              coding:
              - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 30
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 31
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit'}
                mustSupport: true
                index: 32
            required: [code]
        billingnetworkcontractingstatus:
          match:
            category:
              coding:
              - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 11
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 12
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'}
                mustSupport: true
                index: 13
            required: [code]
        admissionperiod:
          match:
            category:
              coding:
              - {code: admissionperiod, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            _required: true
            index: 14
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: admissionperiod, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 15
              timing:
                choices: []
                index: 17
              timingPeriod: {type: Period, mustSupport: true, index: 18}
            required: [timingPeriod, timing]
        clmrecvddate:
          match:
            category:
              coding:
              - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 19
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 20
              timing:
                mustSupport: true
                choices: [timingDate]
                index: 22
              timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 23}
            required: [timingDate, timing]
        medicalrecordnumber:
          match:
            category:
              coding:
              - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 39
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: medicalrecordnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 40
              value:
                choices: []
                index: 42
              valueString: {type: string, mustSupport: true, index: 43}
            required: [valueString, value]
        patientaccountnumber:
          match:
            category:
              coding:
              - {code: patientaccountnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
          schema:
            mustSupport: true
            index: 44
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: patientaccountnumber, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'}
                index: 45
              value:
                choices: []
                index: 47
              valueString: {type: string, mustSupport: true, index: 48}
            required: [valueString, value]
  payment:
    elements:
      date: {mustSupport: true, index: 94}
  item:
    elements:
      revenue:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes'}
        mustSupport: true
        index: 63
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes'}
        mustSupport: true
        index: 64
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers'}
        mustSupport: true
        index: 65
      quantity: {mustSupport: true, index: 66}
      adjudication:
        constraint:
          adjudication-has-amount-type-slice: {human: 'If Adjudication is present, it must have at least one adjudicationamounttype slice', source: 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional', severity: error, expression: '(exists() implies where(category.memberOf(''http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'')).exists())'}
        mustSupport: true
        index: 67
        elements:
          category:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'}
            index: 68
        slicing:
          rules: closed
          ordered: false
          description: Slice based on value pattern
          discriminator:
          - {path: category, type: pattern}
          min: null
          slices:
            adjudicationamounttype:
              match: {category: null}
              schema:
                mustSupport: true
                array: true
                index: 69
                elements:
                  category:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'}
                    index: 70
                  amount: {mustSupport: true, index: 71}
                required: [amount]
            denialreason:
              match:
                category:
                  coding:
                  - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
              schema:
                mustSupport: true
                array: true
                index: 72
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
                    index: 73
                  reason:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'}
                    mustSupport: true
                    index: 74
                required: [reason]
            allowedunits:
              match:
                category:
                  coding:
                  - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
              schema:
                mustSupport: true
                index: 75
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'}
                    index: 76
                  value: {mustSupport: true, index: 77}
                required: [value]
    required: [revenue]
  type:
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: institutional, system: 'http://terminology.hl7.org/CodeSystem/claim-type'}
    index: 1
  created: {mustSupport: true, index: 6}
  procedure:
    mustSupport: true
    index: 56
    elements:
      sequence: {index: 57}
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType'}
        mustSupport: true
        index: 58
      date: {mustSupport: true, index: 59}
      procedure:
        mustSupport: true
        choices: [procedureCodeableConcept]
        index: 61
      procedureCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: procedure, index: 62}
    required: [type]
  total:
    array: true
    min: 2
    index: 86
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator'}
        mustSupport: true
        index: 87
      amount: {index: 88}
    slicing:
      rules: open
      ordered: false
      description: Slice based on value pattern
      discriminator:
      - {path: category, type: pattern}
      min: 2
      slices:
        adjudicationamounttype:
          match: {category: null}
          schema:
            mustSupport: true
            array: true
            min: 1
            _required: true
            index: 89
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'}
                index: 90
              amount: {mustSupport: true, index: 91}
        benefitpaymentstatus:
          match: {category: null}
          schema:
            mustSupport: true
            _required: true
            index: 92
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'}
                index: 93
  billablePeriod:
    index: 3
    elements:
      start: {mustSupport: true, index: 4}
      end: {mustSupport: true, index: 5}
  subType:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType'}
    mustSupport: true
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: inpatient, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType'}
    index: 2
  provider:
    type: Reference
    refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization']
    index: 7
  careTeam:
    constraint:
      EOB-inst-careTeam-practitioner:
        human: 'Institutional EOB: Careteam roles refer to a practitioner'
        source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional
        severity: error
        expression: |-
          (
          role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies
          role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner)
          )
      EOB-inst-careTeam-organization:
        human: 'Institutional EOB:  Careteam roles refer to an organization'
        source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional
        severity: error
        expression: |-
          (
          role.where(coding.where(code in ('performing' )).exists()).exists() implies
          role.where(coding.where(code in ('performing' )).exists()).exists().provider.all(resolve() is Organization)
          )
    index: 8
    elements:
      role:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole'}
        index: 9
    required: [role]
package_version: bb-1.1.0
class: profile
kind: resource
url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional
base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit
version: 1.1.0
required: [diagnosis, billablePeriod, supportingInfo, subType]