description: This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. \nThe claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services. package_name: hl7.fhir.us.carin-bb derivation: constraint name: C4BBExplanationOfBenefitOutpatientInstitutional type: ExplanationOfBenefit elements: processNote: elements: text: {mustSupport: true, index: 70} diagnosis: index: 27 elements: sequence: {index: 28} diagnosis: mustSupport: true choices: [diagnosisCodeableConcept] index: 30 diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 31} type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimOutpatientInstitutionalDiagnosisType'} mustSupport: true index: 32 required: [type] adjudication: type: BackboneElement constraint: ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())} 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-Outpatient-Institutional', severity: error, expression: '(exists() implies where(category.memberOf(''http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'')).exists())'} mustSupport: true index: 53 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} mustSupport: true index: 54 slicing: rules: closed ordered: false description: Slice based on value pattern discriminator: - {path: category, type: pattern} min: null slices: adjudicationamounttype: match: {category: null} schema: array: true index: 55 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 56 amount: {mustSupport: true, index: 57} required: [amount] denialreason: match: category: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: array: true index: 58 elements: category: pattern: type: CodeableConcept value: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 59 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'} mustSupport: true index: 60 required: [reason] supportingInfo: index: 6 slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: category, type: pattern} min: null slices: billingnetworkcontractingstatus: match: category: coding: - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 7 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: billingnetworkcontractingstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 8 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderContractingStatus'} mustSupport: true index: 9 required: [code] clmrecvddate: match: category: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 10 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 11 timing: mustSupport: true choices: [timingDate] index: 13 timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 14} required: [timingDate, timing] typeofbill: match: category: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 15 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 16 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill'} mustSupport: true index: 17 required: [code] pointoforigin: match: category: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 18 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 19 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit'} mustSupport: true index: 20 admtype: match: category: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 21 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 22 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit'} mustSupport: true index: 23 required: [code] discharge-status: match: category: coding: - {code: discharge-status, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: index: 24 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: discharge-status, 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/AHANUBCPatientDischargeStatus'} mustSupport: true index: 26 required: [code] payment: elements: date: {mustSupport: true, index: 69} item: index: 33 elements: revenue: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes'} mustSupport: true index: 34 productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes'} mustSupport: true index: 35 modifier: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers'} mustSupport: true index: 36 serviced: choices: [servicedDate] index: 38 servicedDate: {type: date, choiceOf: serviced, index: 39} quantity: {mustSupport: true, index: 41} adjudication: constraint: ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())} 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-Outpatient-Institutional', severity: error, expression: '(exists() implies where(category.memberOf(''http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'')).exists())'} mustSupport: true index: 42 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} index: 43 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: 44 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 45 amount: {mustSupport: true, index: 46} denialreason: match: category: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: mustSupport: true array: true index: 47 elements: category: pattern: type: CodeableConcept value: coding: - {code: denialreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 48 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes'} mustSupport: true index: 49 required: [reason] allowedunits: match: category: coding: - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: mustSupport: true index: 50 elements: category: pattern: type: CodeableConcept value: coding: - {code: allowedunits, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 51 value: {mustSupport: true, index: 52} type: pattern: type: CodeableConcept value: coding: - {code: institutional, system: 'http://terminology.hl7.org/CodeSystem/claim-type'} index: 0 created: {mustSupport: true, index: 1} total: index: 61 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator'} mustSupport: true index: 62 amount: {index: 63} slicing: rules: open ordered: false description: Slice based on value pattern discriminator: - {path: category, type: pattern} min: null slices: adjudicationamounttype: match: {category: null} schema: array: true min: 1 _required: true index: 64 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication'} index: 65 amount: {mustSupport: true, index: 66} inoutnetwork: match: {category: null} schema: index: 67 elements: category: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'} index: 68 provider: type: Reference refers: ['http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization'] index: 2 careTeam: constraint: ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())} EOB-inst-careTeam-practitioner: human: 'Institutional EOB: Careteam roles refer to a practitioner' source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-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-Outpatient-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) ) EOB-careteam-qualification: human: Care Team Performing physician's qualifications are from US-Core-Provider-Specialty Value Set source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional severity: error expression: |- ( role.where(coding.where(code in ('performing' )).exists()).exists() implies role.where(coding.where(code in ('performing' )).exists()).exists().qualification.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-provider-specialty') ) index: 3 elements: role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole'} index: 4 qualification: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-provider-specialty'} index: 5 required: [role] package_version: 1.0.0 class: profile kind: resource url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit version: 1.0.0 required: [diagnosis]