{
"description": "Base StructureDefinition for ExplanationOfBenefit Resource",
"_filename": "StructureDefinition-ExplanationOfBenefit.json",
"package_name": "hl7.fhir.r3.examples",
"date": "2019-10-24T11:53:00+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2019-10-24T11:53:00+11:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "3.0.2",
"name": "ExplanationOfBenefit",
"mapping": [ {
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping",
"identity": "w5"
}, {
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard",
"identity": "cdanetv4"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": false,
"type": "ExplanationOfBenefit",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "3.0.2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
} ],
"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": "DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-1",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.text.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": "DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()"
} ],
"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.",
"short": "Explanation of Benefit resource",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "financial.other",
"identity": "w5"
} ],
"alias": [ "EOB" ],
"max": "*",
"id": "ExplanationOfBenefit"
}, {
"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.",
"short": "Logical id of this artifact",
"type": [ {
"code": "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
}, {
"path": "ExplanationOfBenefit.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "ExplanationOfBenefit.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"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.",
"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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"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"
}
}, {
"path": "ExplanationOfBenefit.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource, and may 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.",
"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",
"condition": [ "dom-1" ],
"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 in formation is added later.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
}
}, {
"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.",
"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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "ExplanationOfBenefit.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.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. Usually modifier elements provide negation or qualification. In order 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.",
"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"
}
}, {
"id": "ExplanationOfBenefit.identifier",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Business Identifier",
"mapping": [ {
"map": "id",
"identity": "w5"
} ],
"definition": "The EOB Business Identifier."
}, {
"path": "ExplanationOfBenefit.status",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ExplanationOfBenefitStatus"
} ],
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status"
}
},
"max": "1",
"id": "ExplanationOfBenefit.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"isSummary": true
}, {
"path": "ExplanationOfBenefit.type",
"min": 0,
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"short": "Type or discipline",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"max": "1",
"id": "ExplanationOfBenefit.type",
"comment": "Affects which fields and value sets are used."
}, {
"path": "ExplanationOfBenefit.subType",
"min": 0,
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"short": "Finer grained claim type information",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"max": "*",
"id": "ExplanationOfBenefit.subType",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"id": "ExplanationOfBenefit.patient",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.patient",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
} ],
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "C06,C07,C08, C05, C04",
"identity": "cdanetv4"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"definition": "Patient Resource."
}, {
"id": "ExplanationOfBenefit.billablePeriod",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.billablePeriod",
"type": [ {
"code": "Period"
} ],
"short": "Period for charge submission",
"mapping": [ {
"map": "when.done",
"identity": "w5"
} ],
"definition": "The billable period for which charges are being submitted."
}, {
"id": "ExplanationOfBenefit.created",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.created",
"type": [ {
"code": "dateTime"
} ],
"short": "Creation date",
"mapping": [ {
"map": "when.recorded",
"identity": "w5"
} ],
"definition": "The date when the EOB was created."
}, {
"id": "ExplanationOfBenefit.enterer",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.enterer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Author",
"mapping": [ {
"map": "who.author",
"identity": "w5"
} ],
"definition": "The person who created the explanation of benefit."
}, {
"id": "ExplanationOfBenefit.insurer",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.insurer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Insurer responsible for the EOB",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.author",
"identity": "w5"
} ],
"definition": "The insurer which is responsible for the explanation of benefit."
}, {
"id": "ExplanationOfBenefit.provider",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Responsible provider for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The provider which is responsible for the claim."
}, {
"id": "ExplanationOfBenefit.organization",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.organization",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Responsible organization for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The provider which is responsible for the claim."
}, {
"id": "ExplanationOfBenefit.referral",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.referral",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
} ],
"short": "Treatment Referral",
"mapping": [ {
"map": "B05",
"identity": "cdanetv4"
}, {
"map": "who.cause",
"identity": "w5"
} ],
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information."
}, {
"id": "ExplanationOfBenefit.facility",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.facility",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"short": "Servicing Facility",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"definition": "Facility where the services were provided."
}, {
"id": "ExplanationOfBenefit.claim",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claim",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Claim reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
}, {
"map": "why",
"identity": "w5"
} ],
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number."
}, {
"id": "ExplanationOfBenefit.claimResponse",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claimResponse",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
} ],
"short": "Claim response reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number."
}, {
"id": "ExplanationOfBenefit.outcome",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "complete | error | partial",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
} ],
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
},
"definition": "Processing outcome errror, partial or complete processing."
}, {
"id": "ExplanationOfBenefit.disposition",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.disposition",
"type": [ {
"code": "string"
} ],
"short": "Disposition Message",
"comment": "Do we need a disposition code?",
"definition": "A description of the status of the adjudication."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.related",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"short": "Related Claims which may be revelant to processing this claim",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"max": "*",
"id": "ExplanationOfBenefit.related"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.related.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.related.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.related.claim",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.claim",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Reference to the related claim",
"comment": "Do we need a relationship code?",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services."
}, {
"id": "ExplanationOfBenefit.related.relationship",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.relationship",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "How the reference claim is related",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
} ],
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
"definition": "For example prior or umbrella."
}, {
"id": "ExplanationOfBenefit.related.reference",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.reference",
"type": [ {
"code": "Identifier"
} ],
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # ."
}, {
"id": "ExplanationOfBenefit.prescription",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.prescription",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
} ],
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only."
}, {
"id": "ExplanationOfBenefit.originalPrescription",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalPrescription",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
} ],
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payee",
"min": 0,
"definition": "The party to be reimbursed for the services.",
"short": "Party to be paid any benefits payable",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payee"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.payee.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.payee.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.payee.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of party: Subscriber, Provider, other",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"definition": "Type of Party to be reimbursed: Subscriber, provider, other."
}, {
"id": "ExplanationOfBenefit.payee.resourceType",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.resourceType",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "organization | patient | practitioner | relatedperson",
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeResourceType"
} ],
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/resource-type-link"
}
},
"definition": "organization | patient | practitioner | relatedperson."
}, {
"id": "ExplanationOfBenefit.payee.party",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.party",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
} ],
"short": "Party to receive the payable",
"mapping": [ {
"map": "B03, B04",
"identity": "cdanetv4"
} ],
"definition": "Party to be reimbursed: Subscriber, provider, other."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.information",
"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. Often there are mutiple jurisdiction specific valuesets which are required.",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"max": "*",
"id": "ExplanationOfBenefit.information"
}, {
"path": "ExplanationOfBenefit.information.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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.information.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "ExplanationOfBenefit.information.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ExplanationOfBenefit.information.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"
}
}, {
"path": "ExplanationOfBenefit.information.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ExplanationOfBenefit.information.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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.information.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.information.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link."
}, {
"path": "ExplanationOfBenefit.information.category",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"short": "General class of information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
} ],
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.information.category",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"path": "ExplanationOfBenefit.information.code",
"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 which may influence the adjudication.",
"short": "Type of information",
"mapping": [ {
"map": "F23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
} ],
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
"max": "1",
"id": "ExplanationOfBenefit.information.code",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"id": "ExplanationOfBenefit.information.timing[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.timing[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "When it occurred",
"mapping": [ {
"map": "F24",
"identity": "cdanetv4"
} ],
"definition": "The date when or period to which this information refers."
}, {
"id": "ExplanationOfBenefit.information.value[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.value[x]",
"type": [ {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
} ],
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data."
}, {
"id": "ExplanationOfBenefit.information.reason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.reason",
"type": [ {
"code": "Coding"
} ],
"short": "Reason associated with the information",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.careTeam",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"short": "Care Team members",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "ExplanationOfBenefit.careTeam"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.careTeam.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.careTeam.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.careTeam.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Number to covey order of careteam",
"definition": "Sequence of careteam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careteam members."
}, {
"id": "ExplanationOfBenefit.careTeam.provider",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Member of the Care Team",
"mapping": [ {
"map": "who.actor",
"identity": "w5"
} ],
"definition": "The members of the team who provided the overall service."
}, {
"id": "ExplanationOfBenefit.careTeam.responsible",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.responsible",
"type": [ {
"code": "boolean"
} ],
"short": "Billing practitioner",
"definition": "The practitioner who is billing and responsible for the claimed services rendered to the patient."
}, {
"id": "ExplanationOfBenefit.careTeam.role",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.role",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Role on the team",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
},
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team."
}, {
"id": "ExplanationOfBenefit.careTeam.qualification",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.qualification",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type, classification or Specialization",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
"definition": "The qualification which is applicable for this service."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.diagnosis",
"min": 0,
"definition": "Ordered list of patient diagnosis for which care is sought.",
"short": "List of Diagnosis",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "ExplanationOfBenefit.diagnosis"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.diagnosis.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.diagnosis.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.diagnosis.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses."
}, {
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"definition": "The diagnosis.",
"short": "Patient's diagnosis",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.diagnosis[x]"
}, {
"path": "ExplanationOfBenefit.diagnosis.type",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
} ],
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
"max": "*",
"id": "ExplanationOfBenefit.diagnosis.type",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc."
}, {
"path": "ExplanationOfBenefit.diagnosis.packageCode",
"requirements": "Required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.packageCode"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.procedure",
"min": 0,
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"short": "Procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"id": "ExplanationOfBenefit.procedure"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.procedure.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.procedure.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.procedure.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures."
}, {
"path": "ExplanationOfBenefit.procedure.date",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"definition": "Date and optionally time the procedure was performed .",
"short": "When the procedure was performed",
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.date",
"comment": "SB DateTime??"
}, {
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"definition": "The procedure code.",
"short": "Patient's list of procedures performed",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
"max": "1",
"id": "ExplanationOfBenefit.procedure.procedure[x]"
}, {
"id": "ExplanationOfBenefit.precedence",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.precedence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Precedence (primary, secondary, etc.)",
"definition": "Precedence (primary, secondary, etc.).",
"requirements": "Health care programs and insurers are significant payors of health service costs."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.insurance",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Financial instrument by which payment information for health care.",
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "1",
"id": "ExplanationOfBenefit.insurance"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.insurance.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.insurance.coverage",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
} ],
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
}, {
"path": "ExplanationOfBenefit.insurance.preAuthRef",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"definition": "A list of references from the Insurer to which these services pertain.",
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ExplanationOfBenefit.insurance.preAuthRef"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.accident",
"min": 0,
"definition": "An accident which resulted in the need for healthcare services.",
"short": "Details of an accident",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.accident.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.accident.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accident.date",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"definition": "Date of an accident which these services are addressing.",
"short": "When the accident occurred",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident.date"
}, {
"path": "ExplanationOfBenefit.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "Type of accident: work, auto, etc.",
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
"max": "1",
"id": "ExplanationOfBenefit.accident.type"
}, {
"id": "ExplanationOfBenefit.accident.location[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident.location[x]",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"short": "Accident Place",
"definition": "Where the accident occurred."
}, {
"id": "ExplanationOfBenefit.employmentImpacted",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.employmentImpacted",
"type": [ {
"code": "Period"
} ],
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)."
}, {
"id": "ExplanationOfBenefit.hospitalization",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.hospitalization",
"type": [ {
"code": "Period"
} ],
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item",
"min": 0,
"definition": "First tier of goods and services.",
"short": "Goods and Services",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.item.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.item.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ExplanationOfBenefit.item.careTeamLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.careTeamLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable careteam members",
"definition": "Careteam applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.diagnosisLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.diagnosisLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.procedureLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.procedureLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.informationLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.informationLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.service",
"min": 0,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"short": "Billing Code",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.service"
}, {
"path": "ExplanationOfBenefit.item.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.modifier"
}, {
"id": "ExplanationOfBenefit.item.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.serviced[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.serviced[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "Date or dates of Service",
"mapping": [ {
"map": "F09",
"identity": "cdanetv4"
}, {
"map": "when.done",
"identity": "w5"
} ],
"definition": "The date or dates when the enclosed suite of services were performed or completed."
}, {
"path": "ExplanationOfBenefit.item.location[x]",
"min": 0,
"definition": "Where the service was provided.",
"short": "Place of service",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.location[x]"
}, {
"id": "ExplanationOfBenefit.item.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"id": "ExplanationOfBenefit.item.unitPrice",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F12",
"identity": "cdanetv4"
} ],
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group."
}, {
"path": "ExplanationOfBenefit.item.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.factor"
}, {
"path": "ExplanationOfBenefit.item.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Total item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.net"
}, {
"id": "ExplanationOfBenefit.item.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"path": "ExplanationOfBenefit.item.bodySite",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc).",
"short": "Service Location",
"mapping": [ {
"map": "F10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.bodySite"
}, {
"path": "ExplanationOfBenefit.item.subSite",
"min": 0,
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"short": "Service Sub-location",
"mapping": [ {
"map": "F11",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.subSite"
}, {
"id": "ExplanationOfBenefit.item.encounter",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.encounter",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
} ],
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters."
}, {
"id": "ExplanationOfBenefit.item.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.adjudication",
"min": 0,
"definition": "The adjudications results.",
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.adjudication"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.adjudication.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.item.adjudication.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.item.adjudication.category",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.adjudication.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc."
}, {
"id": "ExplanationOfBenefit.item.adjudication.reason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.reason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Explanation of Adjudication outcome",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
} ],
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"definition": "Adjudication reason such as limit reached."
}, {
"id": "ExplanationOfBenefit.item.adjudication.amount",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.amount",
"type": [ {
"code": "Money"
} ],
"short": "Monetary amount",
"definition": "Monitory amount associated with the code."
}, {
"id": "ExplanationOfBenefit.item.adjudication.value",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.value",
"type": [ {
"code": "decimal"
} ],
"short": "Non-monitory value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail",
"min": 0,
"definition": "Second tier of goods and services.",
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.item.detail"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.item.detail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.item.detail.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"path": "ExplanationOfBenefit.item.detail.type",
"min": 1,
"definition": "The type of product or service.",
"short": "Group or type of product or service",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ItemType"
} ],
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.type",
"comment": "ItemType."
}, {
"id": "ExplanationOfBenefit.item.detail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.detail.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.detail.service",
"min": 0,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"short": "Billing Code",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.service"
}, {
"path": "ExplanationOfBenefit.item.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.modifier"
}, {
"id": "ExplanationOfBenefit.item.detail.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.detail.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "ExplanationOfBenefit.item.detail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.unitPrice"
}, {
"path": "ExplanationOfBenefit.item.detail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.factor"
}, {
"path": "ExplanationOfBenefit.item.detail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Total additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.net"
}, {
"id": "ExplanationOfBenefit.item.detail.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"id": "ExplanationOfBenefit.item.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.item.detail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.item.detail.subDetail",
"min": 0,
"definition": "Third tier of goods and services.",
"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"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.type",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of product or service",
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ItemType"
} ],
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"definition": "The type of product or service."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"min": 0,
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"short": "Billing Code",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.service"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.modifier"
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The fee for an addittional service or product or charge.",
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.factor"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Net additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.net"
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"short": "Language if different from the resource",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem",
"min": 0,
"definition": "The first tier service adjudications for payor added services.",
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.addItem.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.addItem.sequenceLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace."
}, {
"id": "ExplanationOfBenefit.addItem.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"path": "ExplanationOfBenefit.addItem.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.category"
}, {
"id": "ExplanationOfBenefit.addItem.service",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Billing Code",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'."
}, {
"path": "ExplanationOfBenefit.addItem.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.modifier"
}, {
"id": "ExplanationOfBenefit.addItem.fee",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product."
}, {
"id": "ExplanationOfBenefit.addItem.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.addItem.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.addItem.detail",
"min": 0,
"definition": "The second tier service adjudications for payor added services.",
"short": "Added items details",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.addItem.detail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.addItem.detail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"path": "ExplanationOfBenefit.addItem.detail.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.category"
}, {
"id": "ExplanationOfBenefit.addItem.detail.service",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Billing Code",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)."
}, {
"path": "ExplanationOfBenefit.addItem.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.modifier"
}, {
"id": "ExplanationOfBenefit.addItem.detail.fee",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product."
}, {
"id": "ExplanationOfBenefit.addItem.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.addItem.detail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication",
"short": "Added items detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"id": "ExplanationOfBenefit.totalCost",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalCost",
"type": [ {
"code": "Money"
} ],
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns."
}, {
"id": "ExplanationOfBenefit.unallocDeductable",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.unallocDeductable",
"type": [ {
"code": "Money"
} ],
"short": "Unallocated deductable",
"definition": "The amount of deductable applied which was not allocated to any particular service line."
}, {
"id": "ExplanationOfBenefit.totalBenefit",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalBenefit",
"type": [ {
"code": "Money"
} ],
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.payment",
"min": 0,
"definition": "Payment details for the claim if the claim has been paid.",
"short": "Payment (if paid)",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payment"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.payment.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.payment.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.payment.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Partial or Complete",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
} ],
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
},
"definition": "Whether this represents partial or complete payment of the claim."
}, {
"id": "ExplanationOfBenefit.payment.adjustment",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustment",
"type": [ {
"code": "Money"
} ],
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction."
}, {
"id": "ExplanationOfBenefit.payment.adjustmentReason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustmentReason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Explanation for the non-claim adjustment",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
} ],
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"definition": "Reason for the payment adjustment."
}, {
"id": "ExplanationOfBenefit.payment.date",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.date",
"type": [ {
"code": "date"
} ],
"short": "Expected date of Payment",
"definition": "Estimated payment date."
}, {
"id": "ExplanationOfBenefit.payment.amount",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.amount",
"type": [ {
"code": "Money"
} ],
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment."
}, {
"id": "ExplanationOfBenefit.payment.identifier",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Identifier of the payment instrument",
"mapping": [ {
"map": "G01, B.23",
"identity": "cdanetv4"
} ],
"definition": "Payment identifer."
}, {
"path": "ExplanationOfBenefit.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"id": "ExplanationOfBenefit.form"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.processNote",
"min": 0,
"definition": "Note text.",
"short": "Processing notes",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"max": "*",
"id": "ExplanationOfBenefit.processNote"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.processNote.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.processNote.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.processNote.number",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.number",
"type": [ {
"code": "positiveInt"
} ],
"short": "Sequence number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item."
}, {
"id": "ExplanationOfBenefit.processNote.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "display | print | printoper",
"binding": {
"strength": "required",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"definition": "The note purpose: Print/Display."
}, {
"id": "ExplanationOfBenefit.processNote.text",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.text",
"type": [ {
"code": "string"
} ],
"short": "Note explanitory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"definition": "The note text."
}, {
"id": "ExplanationOfBenefit.processNote.language",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.language",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Language if different from the resource",
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance",
"min": 0,
"definition": "Balance by Benefit Category.",
"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"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.benefitBalance.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.benefitBalance.category",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of services covered",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc."
}, {
"id": "ExplanationOfBenefit.benefitBalance.subCategory",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Detailed services covered within the type",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc."
}, {
"id": "ExplanationOfBenefit.benefitBalance.excluded",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.excluded",
"type": [ {
"code": "boolean"
} ],
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage."
}, {
"id": "ExplanationOfBenefit.benefitBalance.name",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.name",
"type": [ {
"code": "string"
} ],
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2."
}, {
"id": "ExplanationOfBenefit.benefitBalance.description",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.description",
"type": [ {
"code": "string"
} ],
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'."
}, {
"id": "ExplanationOfBenefit.benefitBalance.network",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.network",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "In or out of network",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
} ],
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
},
"definition": "Network designation."
}, {
"id": "ExplanationOfBenefit.benefitBalance.unit",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.unit",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Individual or family",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
} ],
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
},
"definition": "Unit designation: individual or family."
}, {
"id": "ExplanationOfBenefit.benefitBalance.term",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.term",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Annual or lifetime",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
} ],
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
},
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "ExplanationOfBenefit.benefitBalance.financial",
"min": 0,
"definition": "Benefits Used to date.",
"short": "Benefit Summary",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
} ],
"max": "*",
"id": "ExplanationOfBenefit.benefitBalance.financial"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ExplanationOfBenefit.benefitBalance.financial.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"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"
}
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"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"
},
"isSummary": true
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.type",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Deductable, visits, benefit amount",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
} ],
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
},
"definition": "Deductable, visits, benefit amount."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"type": [ {
"code": "unsignedInt"
}, {
"code": "string"
}, {
"code": "Money"
} ],
"short": "Benefits allowed",
"definition": "Benefits allowed."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"type": [ {
"code": "unsignedInt"
}, {
"code": "Money"
} ],
"short": "Benefits used",
"definition": "Benefits used."
} ]
},
"status": "draft",
"id": "f9ce89cf-55b7-4462-9bc8-6fa7a8fae036",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit",
"version": null,
"differential": {
"element": [ {
"id": "ExplanationOfBenefit",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit",
"alias": [ "EOB" ],
"short": "Explanation of Benefit resource",
"mapping": [ {
"map": "financial.other",
"identity": "w5"
} ],
"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."
}, {
"id": "ExplanationOfBenefit.identifier",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Business Identifier",
"mapping": [ {
"map": "id",
"identity": "w5"
} ],
"definition": "The EOB Business Identifier."
}, {
"path": "ExplanationOfBenefit.status",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ExplanationOfBenefitStatus"
} ],
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status"
}
},
"max": "1",
"id": "ExplanationOfBenefit.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"isSummary": true
}, {
"path": "ExplanationOfBenefit.type",
"min": 0,
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"short": "Type or discipline",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"max": "1",
"id": "ExplanationOfBenefit.type",
"comment": "Affects which fields and value sets are used."
}, {
"path": "ExplanationOfBenefit.subType",
"min": 0,
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"short": "Finer grained claim type information",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"max": "*",
"id": "ExplanationOfBenefit.subType",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"id": "ExplanationOfBenefit.patient",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.patient",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
} ],
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "C06,C07,C08, C05, C04",
"identity": "cdanetv4"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"definition": "Patient Resource."
}, {
"id": "ExplanationOfBenefit.billablePeriod",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.billablePeriod",
"type": [ {
"code": "Period"
} ],
"short": "Period for charge submission",
"mapping": [ {
"map": "when.done",
"identity": "w5"
} ],
"definition": "The billable period for which charges are being submitted."
}, {
"id": "ExplanationOfBenefit.created",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.created",
"type": [ {
"code": "dateTime"
} ],
"short": "Creation date",
"mapping": [ {
"map": "when.recorded",
"identity": "w5"
} ],
"definition": "The date when the EOB was created."
}, {
"id": "ExplanationOfBenefit.enterer",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.enterer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Author",
"mapping": [ {
"map": "who.author",
"identity": "w5"
} ],
"definition": "The person who created the explanation of benefit."
}, {
"id": "ExplanationOfBenefit.insurer",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.insurer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Insurer responsible for the EOB",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.author",
"identity": "w5"
} ],
"definition": "The insurer which is responsible for the explanation of benefit."
}, {
"id": "ExplanationOfBenefit.provider",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Responsible provider for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The provider which is responsible for the claim."
}, {
"id": "ExplanationOfBenefit.organization",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.organization",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Responsible organization for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The provider which is responsible for the claim."
}, {
"id": "ExplanationOfBenefit.referral",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.referral",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
} ],
"short": "Treatment Referral",
"mapping": [ {
"map": "B05",
"identity": "cdanetv4"
}, {
"map": "who.cause",
"identity": "w5"
} ],
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information."
}, {
"id": "ExplanationOfBenefit.facility",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.facility",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"short": "Servicing Facility",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"definition": "Facility where the services were provided."
}, {
"id": "ExplanationOfBenefit.claim",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claim",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Claim reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
}, {
"map": "why",
"identity": "w5"
} ],
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number."
}, {
"id": "ExplanationOfBenefit.claimResponse",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claimResponse",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
} ],
"short": "Claim response reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number."
}, {
"id": "ExplanationOfBenefit.outcome",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "complete | error | partial",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
} ],
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
},
"definition": "Processing outcome errror, partial or complete processing."
}, {
"id": "ExplanationOfBenefit.disposition",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.disposition",
"type": [ {
"code": "string"
} ],
"short": "Disposition Message",
"comment": "Do we need a disposition code?",
"definition": "A description of the status of the adjudication."
}, {
"id": "ExplanationOfBenefit.related",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.related",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Related Claims which may be revelant to processing this claim",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"definition": "Other claims which are related to this claim such as prior claim versions or for related services."
}, {
"id": "ExplanationOfBenefit.related.claim",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.claim",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Reference to the related claim",
"comment": "Do we need a relationship code?",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services."
}, {
"id": "ExplanationOfBenefit.related.relationship",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.relationship",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "How the reference claim is related",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
} ],
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
"definition": "For example prior or umbrella."
}, {
"id": "ExplanationOfBenefit.related.reference",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.reference",
"type": [ {
"code": "Identifier"
} ],
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # ."
}, {
"id": "ExplanationOfBenefit.prescription",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.prescription",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
} ],
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only."
}, {
"id": "ExplanationOfBenefit.originalPrescription",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalPrescription",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
} ],
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'."
}, {
"path": "ExplanationOfBenefit.payee",
"min": 0,
"definition": "The party to be reimbursed for the services.",
"short": "Party to be paid any benefits payable",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "ExplanationOfBenefit.payee"
}, {
"id": "ExplanationOfBenefit.payee.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of party: Subscriber, Provider, other",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"definition": "Type of Party to be reimbursed: Subscriber, provider, other."
}, {
"id": "ExplanationOfBenefit.payee.resourceType",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.resourceType",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "organization | patient | practitioner | relatedperson",
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeResourceType"
} ],
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/resource-type-link"
}
},
"definition": "organization | patient | practitioner | relatedperson."
}, {
"id": "ExplanationOfBenefit.payee.party",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.party",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
} ],
"short": "Party to receive the payable",
"mapping": [ {
"map": "B03, B04",
"identity": "cdanetv4"
} ],
"definition": "Party to be reimbursed: Subscriber, provider, other."
}, {
"path": "ExplanationOfBenefit.information",
"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. Often there are mutiple jurisdiction specific valuesets which are required.",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"max": "*",
"id": "ExplanationOfBenefit.information"
}, {
"id": "ExplanationOfBenefit.information.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.information.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link."
}, {
"path": "ExplanationOfBenefit.information.category",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"short": "General class of information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
} ],
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.information.category",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"path": "ExplanationOfBenefit.information.code",
"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 which may influence the adjudication.",
"short": "Type of information",
"mapping": [ {
"map": "F23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
} ],
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
"max": "1",
"id": "ExplanationOfBenefit.information.code",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code."
}, {
"id": "ExplanationOfBenefit.information.timing[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.timing[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "When it occurred",
"mapping": [ {
"map": "F24",
"identity": "cdanetv4"
} ],
"definition": "The date when or period to which this information refers."
}, {
"id": "ExplanationOfBenefit.information.value[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.value[x]",
"type": [ {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
} ],
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data."
}, {
"id": "ExplanationOfBenefit.information.reason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.information.reason",
"type": [ {
"code": "Coding"
} ],
"short": "Reason associated with the information",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content."
}, {
"path": "ExplanationOfBenefit.careTeam",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"short": "Care Team members",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "ExplanationOfBenefit.careTeam"
}, {
"id": "ExplanationOfBenefit.careTeam.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Number to covey order of careteam",
"definition": "Sequence of careteam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careteam members."
}, {
"id": "ExplanationOfBenefit.careTeam.provider",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.careTeam.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Member of the Care Team",
"mapping": [ {
"map": "who.actor",
"identity": "w5"
} ],
"definition": "The members of the team who provided the overall service."
}, {
"id": "ExplanationOfBenefit.careTeam.responsible",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.responsible",
"type": [ {
"code": "boolean"
} ],
"short": "Billing practitioner",
"definition": "The practitioner who is billing and responsible for the claimed services rendered to the patient."
}, {
"id": "ExplanationOfBenefit.careTeam.role",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.role",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Role on the team",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
},
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team."
}, {
"id": "ExplanationOfBenefit.careTeam.qualification",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.careTeam.qualification",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type, classification or Specialization",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
"definition": "The qualification which is applicable for this service."
}, {
"id": "ExplanationOfBenefit.diagnosis",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis",
"type": [ {
"code": "BackboneElement"
} ],
"short": "List of Diagnosis",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"definition": "Ordered list of patient diagnosis for which care is sought."
}, {
"id": "ExplanationOfBenefit.diagnosis.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.diagnosis.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses."
}, {
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"definition": "The diagnosis.",
"short": "Patient's diagnosis",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.diagnosis[x]"
}, {
"path": "ExplanationOfBenefit.diagnosis.type",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
} ],
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
"max": "*",
"id": "ExplanationOfBenefit.diagnosis.type",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc."
}, {
"path": "ExplanationOfBenefit.diagnosis.packageCode",
"requirements": "Required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
},
"max": "1",
"id": "ExplanationOfBenefit.diagnosis.packageCode"
}, {
"id": "ExplanationOfBenefit.procedure",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Procedures performed",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"definition": "Ordered list of patient procedures performed to support the adjudication."
}, {
"id": "ExplanationOfBenefit.procedure.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.procedure.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures."
}, {
"path": "ExplanationOfBenefit.procedure.date",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"definition": "Date and optionally time the procedure was performed .",
"short": "When the procedure was performed",
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "ExplanationOfBenefit.procedure.date",
"comment": "SB DateTime??"
}, {
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"definition": "The procedure code.",
"short": "Patient's list of procedures performed",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
"max": "1",
"id": "ExplanationOfBenefit.procedure.procedure[x]"
}, {
"id": "ExplanationOfBenefit.precedence",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.precedence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Precedence (primary, secondary, etc.)",
"definition": "Precedence (primary, secondary, etc.).",
"requirements": "Health care programs and insurers are significant payors of health service costs."
}, {
"path": "ExplanationOfBenefit.insurance",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Financial instrument by which payment information for health care.",
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "1",
"id": "ExplanationOfBenefit.insurance"
}, {
"id": "ExplanationOfBenefit.insurance.coverage",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
} ],
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
}, {
"path": "ExplanationOfBenefit.insurance.preAuthRef",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"definition": "A list of references from the Insurer to which these services pertain.",
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ExplanationOfBenefit.insurance.preAuthRef"
}, {
"id": "ExplanationOfBenefit.accident",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Details of an accident",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
} ],
"definition": "An accident which resulted in the need for healthcare services."
}, {
"path": "ExplanationOfBenefit.accident.date",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"definition": "Date of an accident which these services are addressing.",
"short": "When the accident occurred",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "ExplanationOfBenefit.accident.date"
}, {
"path": "ExplanationOfBenefit.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "Type of accident: work, auto, etc.",
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
"max": "1",
"id": "ExplanationOfBenefit.accident.type"
}, {
"id": "ExplanationOfBenefit.accident.location[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accident.location[x]",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"short": "Accident Place",
"definition": "Where the accident occurred."
}, {
"id": "ExplanationOfBenefit.employmentImpacted",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.employmentImpacted",
"type": [ {
"code": "Period"
} ],
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)."
}, {
"id": "ExplanationOfBenefit.hospitalization",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.hospitalization",
"type": [ {
"code": "Period"
} ],
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center."
}, {
"id": "ExplanationOfBenefit.item",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Goods and Services",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"definition": "First tier of goods and services."
}, {
"id": "ExplanationOfBenefit.item.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ExplanationOfBenefit.item.careTeamLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.careTeamLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable careteam members",
"definition": "Careteam applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.diagnosisLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.diagnosisLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.procedureLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.procedureLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.informationLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.informationLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line."
}, {
"id": "ExplanationOfBenefit.item.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.service",
"min": 0,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"short": "Billing Code",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.service"
}, {
"path": "ExplanationOfBenefit.item.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.modifier"
}, {
"id": "ExplanationOfBenefit.item.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.serviced[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.serviced[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "Date or dates of Service",
"mapping": [ {
"map": "F09",
"identity": "cdanetv4"
}, {
"map": "when.done",
"identity": "w5"
} ],
"definition": "The date or dates when the enclosed suite of services were performed or completed."
}, {
"path": "ExplanationOfBenefit.item.location[x]",
"min": 0,
"definition": "Where the service was provided.",
"short": "Place of service",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.location[x]"
}, {
"id": "ExplanationOfBenefit.item.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"id": "ExplanationOfBenefit.item.unitPrice",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F12",
"identity": "cdanetv4"
} ],
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group."
}, {
"path": "ExplanationOfBenefit.item.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.factor"
}, {
"path": "ExplanationOfBenefit.item.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Total item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.net"
}, {
"id": "ExplanationOfBenefit.item.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"path": "ExplanationOfBenefit.item.bodySite",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc).",
"short": "Service Location",
"mapping": [ {
"map": "F10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.bodySite"
}, {
"path": "ExplanationOfBenefit.item.subSite",
"min": 0,
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"short": "Service Sub-location",
"mapping": [ {
"map": "F11",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.subSite"
}, {
"id": "ExplanationOfBenefit.item.encounter",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.encounter",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
} ],
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters."
}, {
"id": "ExplanationOfBenefit.item.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.item.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Adjudication details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"definition": "The adjudications results."
}, {
"id": "ExplanationOfBenefit.item.adjudication.category",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.adjudication.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc."
}, {
"id": "ExplanationOfBenefit.item.adjudication.reason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.reason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Explanation of Adjudication outcome",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
} ],
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"definition": "Adjudication reason such as limit reached."
}, {
"id": "ExplanationOfBenefit.item.adjudication.amount",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.amount",
"type": [ {
"code": "Money"
} ],
"short": "Monetary amount",
"definition": "Monitory amount associated with the code."
}, {
"id": "ExplanationOfBenefit.item.adjudication.value",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.value",
"type": [ {
"code": "decimal"
} ],
"short": "Non-monitory value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above."
}, {
"id": "ExplanationOfBenefit.item.detail",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Additional items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"definition": "Second tier of goods and services."
}, {
"id": "ExplanationOfBenefit.item.detail.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"path": "ExplanationOfBenefit.item.detail.type",
"min": 1,
"definition": "The type of product or service.",
"short": "Group or type of product or service",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ItemType"
} ],
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.type",
"comment": "ItemType."
}, {
"id": "ExplanationOfBenefit.item.detail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.detail.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.detail.service",
"min": 0,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"short": "Billing Code",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.service"
}, {
"path": "ExplanationOfBenefit.item.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.modifier"
}, {
"id": "ExplanationOfBenefit.item.detail.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.detail.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "ExplanationOfBenefit.item.detail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.unitPrice"
}, {
"path": "ExplanationOfBenefit.item.detail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.factor"
}, {
"path": "ExplanationOfBenefit.item.detail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Total additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.net"
}, {
"id": "ExplanationOfBenefit.item.detail.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"id": "ExplanationOfBenefit.item.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.item.detail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Additional items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"definition": "Third tier of goods and services."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.type",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.item.detail.subDetail.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of product or service",
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ItemType"
} ],
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"definition": "The type of product or service."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.category",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"min": 0,
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"short": "Billing Code",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.service"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.item.detail.subDetail.modifier"
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Program specific reason for item inclusion",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The fee for an addittional service or product or charge.",
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"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.",
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.factor"
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"short": "Net additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "ExplanationOfBenefit.item.detail.subDetail.net"
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.udi",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"short": "Language if different from the resource",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"id": "ExplanationOfBenefit.addItem",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Insurer added line items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"definition": "The first tier service adjudications for payor added services."
}, {
"id": "ExplanationOfBenefit.addItem.sequenceLinkId",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace."
}, {
"id": "ExplanationOfBenefit.addItem.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"path": "ExplanationOfBenefit.addItem.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.category"
}, {
"id": "ExplanationOfBenefit.addItem.service",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Billing Code",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'."
}, {
"path": "ExplanationOfBenefit.addItem.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.modifier"
}, {
"id": "ExplanationOfBenefit.addItem.fee",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product."
}, {
"id": "ExplanationOfBenefit.addItem.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.addItem.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"id": "ExplanationOfBenefit.addItem.detail",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Added items details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
"definition": "The second tier service adjudications for payor added services."
}, {
"id": "ExplanationOfBenefit.addItem.detail.revenue",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"path": "ExplanationOfBenefit.addItem.detail.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "ExplanationOfBenefit.addItem.detail.category"
}, {
"id": "ExplanationOfBenefit.addItem.detail.service",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Billing Code",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)."
}, {
"path": "ExplanationOfBenefit.addItem.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for 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.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ExplanationOfBenefit.addItem.detail.modifier"
}, {
"id": "ExplanationOfBenefit.addItem.detail.fee",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product."
}, {
"id": "ExplanationOfBenefit.addItem.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ExplanationOfBenefit.addItem.detail.adjudication",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication",
"short": "Added items detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
}, {
"id": "ExplanationOfBenefit.totalCost",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalCost",
"type": [ {
"code": "Money"
} ],
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns."
}, {
"id": "ExplanationOfBenefit.unallocDeductable",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.unallocDeductable",
"type": [ {
"code": "Money"
} ],
"short": "Unallocated deductable",
"definition": "The amount of deductable applied which was not allocated to any particular service line."
}, {
"id": "ExplanationOfBenefit.totalBenefit",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalBenefit",
"type": [ {
"code": "Money"
} ],
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)."
}, {
"id": "ExplanationOfBenefit.payment",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Payment (if paid)",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"definition": "Payment details for the claim if the claim has been paid."
}, {
"id": "ExplanationOfBenefit.payment.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Partial or Complete",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
} ],
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
},
"definition": "Whether this represents partial or complete payment of the claim."
}, {
"id": "ExplanationOfBenefit.payment.adjustment",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustment",
"type": [ {
"code": "Money"
} ],
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction."
}, {
"id": "ExplanationOfBenefit.payment.adjustmentReason",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.adjustmentReason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Explanation for the non-claim adjustment",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
} ],
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"definition": "Reason for the payment adjustment."
}, {
"id": "ExplanationOfBenefit.payment.date",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.date",
"type": [ {
"code": "date"
} ],
"short": "Expected date of Payment",
"definition": "Estimated payment date."
}, {
"id": "ExplanationOfBenefit.payment.amount",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.amount",
"type": [ {
"code": "Money"
} ],
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment."
}, {
"id": "ExplanationOfBenefit.payment.identifier",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payment.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Identifier of the payment instrument",
"mapping": [ {
"map": "G01, B.23",
"identity": "cdanetv4"
} ],
"definition": "Payment identifer."
}, {
"path": "ExplanationOfBenefit.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"id": "ExplanationOfBenefit.form"
}, {
"id": "ExplanationOfBenefit.processNote",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.processNote",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Processing notes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"definition": "Note text."
}, {
"id": "ExplanationOfBenefit.processNote.number",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.number",
"type": [ {
"code": "positiveInt"
} ],
"short": "Sequence number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item."
}, {
"id": "ExplanationOfBenefit.processNote.type",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "display | print | printoper",
"binding": {
"strength": "required",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"definition": "The note purpose: Print/Display."
}, {
"id": "ExplanationOfBenefit.processNote.text",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.text",
"type": [ {
"code": "string"
} ],
"short": "Note explanitory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"definition": "The note text."
}, {
"id": "ExplanationOfBenefit.processNote.language",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.processNote.language",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Language if different from the resource",
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English."
}, {
"id": "ExplanationOfBenefit.benefitBalance",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Balance by Benefit Category",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
} ],
"definition": "Balance by Benefit Category."
}, {
"id": "ExplanationOfBenefit.benefitBalance.category",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of services covered",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc."
}, {
"id": "ExplanationOfBenefit.benefitBalance.subCategory",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Detailed services covered within the type",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc."
}, {
"id": "ExplanationOfBenefit.benefitBalance.excluded",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.excluded",
"type": [ {
"code": "boolean"
} ],
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage."
}, {
"id": "ExplanationOfBenefit.benefitBalance.name",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.name",
"type": [ {
"code": "string"
} ],
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2."
}, {
"id": "ExplanationOfBenefit.benefitBalance.description",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.description",
"type": [ {
"code": "string"
} ],
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'."
}, {
"id": "ExplanationOfBenefit.benefitBalance.network",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.network",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "In or out of network",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
} ],
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
},
"definition": "Network designation."
}, {
"id": "ExplanationOfBenefit.benefitBalance.unit",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.unit",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Individual or family",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
} ],
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
},
"definition": "Unit designation: individual or family."
}, {
"id": "ExplanationOfBenefit.benefitBalance.term",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.term",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Annual or lifetime",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
} ],
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
},
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial",
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Benefit Summary",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
} ],
"definition": "Benefits Used to date."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.type",
"max": "1",
"min": 1,
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Deductable, visits, benefit amount",
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
} ],
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
},
"definition": "Deductable, visits, benefit amount."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"type": [ {
"code": "unsignedInt"
}, {
"code": "string"
}, {
"code": "Money"
} ],
"short": "Benefits allowed",
"definition": "Benefits allowed."
}, {
"id": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"type": [ {
"code": "unsignedInt"
}, {
"code": "Money"
} ],
"short": "Benefits used",
"definition": "Benefits used."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}