{
"description": "Base StructureDefinition for ExplanationOfBenefit Resource",
"_filename": "StructureDefinition-ExplanationOfBenefit.json",
"package_name": "hl7.fhir.r2b.core",
"date": null,
"derivation": "specialization",
"meta": {
"lastUpdated": "2016-03-31T08:01:25.570+11:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "1.6.0",
"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",
"identity": "v2"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM",
"identity": "rim"
} ],
"baseType": "ExplanationOfBenefit",
"abstract": false,
"type": null,
"experimental": "false",
"resourceType": "StructureDefinition",
"title": null,
"package_version": "1.4.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 0
} ],
"snapshot": {
"element": [ {
"path": "ExplanationOfBenefit",
"min": 0,
"definition": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"isModifier": false,
"short": "Explanation of Benefit resource",
"mapping": [ {
"map": "financial.other",
"identity": "w5"
} ],
"mustSupport": false,
"alias": [ "EOB" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"isModifier": false,
"short": "Logical id of this artifact",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.",
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"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.",
"isModifier": false,
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"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",
"comments": "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 as much as possible.",
"type": [ {
"code": "uri"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"comments": "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).",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "A human language.",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
},
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Resource.language"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Text summary of the resource, for human interpretation",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"mustSupport": false,
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"condition": [ "dom-1" ],
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"isModifier": false,
"short": "Contained, inline Resources",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"mustSupport": false,
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.identifier",
"min": 0,
"definition": "The Response Business Identifier.",
"isModifier": false,
"short": "Business Identifier",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.claim[x]",
"min": 0,
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"isModifier": false,
"short": "Claim reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claim[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.claimResponse[x]",
"min": 0,
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"isModifier": false,
"short": "Claim response reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claimResponse[x]"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Finer grained claim type information",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.subType"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.ruleset",
"min": 0,
"definition": "The version of the specification on which this instance relies.",
"isModifier": false,
"short": "Current specification followed",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"alias": [ "BusinessVersion" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.ruleset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.originalRuleset",
"min": 0,
"definition": "The version of the specification from which the original instance was created.",
"isModifier": false,
"short": "Original specification followed",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"alias": [ "OriginalBusinessVersion" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalRuleset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.created",
"min": 0,
"definition": "The date when the EOB was created.",
"isModifier": false,
"short": "Creation date",
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.created"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.billablePeriod",
"min": 0,
"definition": "The billable period for which charges are being submitted.",
"isModifier": false,
"short": "Period for charge submission",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.billablePeriod"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.disposition",
"min": 0,
"definition": "A description of the status of the adjudication.",
"isModifier": false,
"short": "Disposition Message",
"comments": "Do we need a disposition code?",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.disposition"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.provider[x]",
"min": 0,
"definition": "The provider which is responsible for the claim.",
"isModifier": false,
"short": "Responsible provider for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.provider[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.organization[x]",
"min": 0,
"definition": "The provider which is responsible for the claim.",
"isModifier": false,
"short": "Responsible organization for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.organization[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.facility[x]",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing Facility",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.facility[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"isModifier": false,
"short": "Related Claims which may be revelant to processing this claimn",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaims"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.related"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.claim[x]",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"isModifier": false,
"short": "Reference to the related claim",
"comments": "Do we need a relationship code?",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.claim[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.relationship",
"min": 0,
"definition": "For example prior or umbrella.",
"isModifier": false,
"short": "How the reference claim is related",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.relationship"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.reference",
"min": 0,
"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 # .",
"isModifier": false,
"short": "Related file or case reference",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.reference"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.prescription[x]",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"isModifier": false,
"short": "Prescription",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/MedicationOrder" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.prescription[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.originalPrescription[x]",
"min": 0,
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.",
"isModifier": false,
"short": "Original Prescription",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/MedicationOrder" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalPrescription[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee",
"min": 0,
"definition": "The party to be reimbursed for the services.",
"isModifier": false,
"short": "Payee",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee.type",
"min": 0,
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"short": "Type of party: Subscriber, Provider, other",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee.party[x]",
"min": 0,
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"short": "Party to receive the payable",
"mapping": [ {
"map": "B03, B04",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.party[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.referral[x]",
"min": 0,
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"isModifier": false,
"short": "Treatment Referral",
"mapping": [ {
"map": "B05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/ReferralRequest" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.referral[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.occurrenceCode",
"min": 0,
"definition": "**Insert definition of Occurrence codes.",
"isModifier": false,
"short": "Occurrence Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Occurrence codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/occurrence-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.occurrenceCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.occurenceSpanCode",
"min": 0,
"definition": "**Insert definition of Occurrence Span codes.",
"isModifier": false,
"short": "Occurrence Span Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Occurrence Span codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/occurrence-span-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.occurenceSpanCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.valueCode",
"min": 0,
"definition": "**Insert definition of Value codes.",
"isModifier": false,
"short": "Value Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Value code",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/value-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.valueCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis",
"min": 0,
"definition": "Ordered list of patient diagnosis for which care is sought.",
"isModifier": false,
"short": "Diagnosis",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis.sequence",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"isModifier": false,
"short": "Number to covey order of diagnosis",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis.diagnosis",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"definition": "The diagnosis.",
"isModifier": false,
"short": "Patient's list of diagnosis",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.diagnosis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure",
"min": 0,
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"isModifier": false,
"short": "Procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.sequence",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"definition": "Sequence of procedures which serves to order and provide a link.",
"isModifier": false,
"short": "Procedure sequence for reference",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.date",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"definition": "Date and optionally time the procedure was performed .",
"isModifier": false,
"short": "When the procedure was performed",
"comments": "SB DateTime??",
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.date"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"definition": "The procedure code.",
"isModifier": false,
"short": "Patient's list of procedures performed",
"type": [ {
"code": "Coding"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.procedure[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.specialCondition",
"min": 0,
"definition": "List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"isModifier": false,
"short": "List of special Conditions",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.specialCondition"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.patient[x]",
"min": 1,
"definition": "Patient Resource.",
"isModifier": false,
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "C06,C07,C08, C05, C04",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.patient[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.precedence",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Precedence (primary, secondary, etc.).",
"isModifier": false,
"short": "Precedence (primary, secondary, etc.)",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.precedence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 1,
"definition": "Financial instrument by which payment information for health care.",
"isModifier": false,
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.coverage"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.coverage.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.coverage.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage.coverage[x]",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"definition": "Reference to the program or plan identification, underwriter or payor.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.coverage.coverage[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage.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.",
"isModifier": false,
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.coverage.preAuthRef"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentDate",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"definition": "Date of an accident which these services are addressing.",
"isModifier": false,
"short": "When the accident occurred",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentType",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "Type of accident: work, auto, etc.",
"isModifier": false,
"short": "The nature of the accident",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentType"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentLocation[x]",
"min": 0,
"definition": "Accident Place.",
"isModifier": false,
"short": "Accident Place",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentLocation[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.interventionException",
"requirements": "Coverage may be modified based on exception information provided.",
"min": 0,
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"isModifier": false,
"short": "Intervention and exception code (Pharma)",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Intervention and exception codes (Pharm)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.interventionException"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset",
"min": 0,
"definition": "Period, start and last dates of aspects of the Condition or related services.",
"isModifier": false,
"short": "Condition related Onset related dates and codes",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Onset"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.onset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.onset.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.onset.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset.time[x]",
"min": 0,
"definition": "The start or start and end dates for the treatable condition.",
"isModifier": false,
"short": "Illness, injury or treatable condition date",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.onset.time[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset.type",
"min": 0,
"definition": "Onset typifications eg. Start of pregnancy, start of illnes, etc.",
"isModifier": false,
"short": "Onset of what",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Condition related start, end and period codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-onsettype"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.onset.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.employmentImpacted",
"min": 0,
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"isModifier": false,
"short": "Period unable to work",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.employmentImpacted"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.hospitalization",
"min": 0,
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"isModifier": false,
"short": "Period in hospital",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.hospitalization"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item",
"min": 0,
"definition": "First tier of goods and services.",
"isModifier": false,
"short": "Goods and Services",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Group or type of product or service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.provider[x]",
"min": 0,
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"isModifier": false,
"short": "Responsible practitioner",
"mapping": [ {
"map": "24G&H not sure",
"identity": "rim"
}, {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.provider[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.supervisor[x]",
"min": 0,
"definition": "The practitioner who is supervising the work of the servicing provider(s).",
"isModifier": false,
"short": "Supervising Practitioner",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.supervisor[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.providerQualification",
"min": 0,
"definition": "The qualification which is applicable for this service.",
"isModifier": false,
"short": "Type, classification or Specialization",
"mapping": [ {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.providerQualification"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.diagnosisLinkId",
"min": 0,
"definition": "Diagnosis applicable for this service or product line.",
"isModifier": false,
"short": "Applicable diagnoses",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.diagnosisLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.service",
"min": 1,
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Item Code",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.serviceModifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Unusual circumstances which may influence adjudication.",
"isModifier": false,
"short": "Service/Product modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Factors which may influce adjudication of services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-modifiers"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.serviceModifier"
},
"isSummary": true
}, {
"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 an appliance was lost or stolen.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"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": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.modifier"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.serviced[x]",
"min": 0,
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"isModifier": false,
"short": "Date or dates of Service",
"mapping": [ {
"map": "F09",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.serviced[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.place",
"min": 0,
"definition": "Where the service was provided.",
"isModifier": false,
"short": "Place of service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.place"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.quantity"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.unitPrice",
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F12",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.bodySite",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc).",
"isModifier": false,
"short": "Service Location",
"mapping": [ {
"map": "F10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.bodySite"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.subSite",
"min": 0,
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"isModifier": false,
"short": "Service Sub-location",
"mapping": [ {
"map": "F11",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.subSite"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.noteNumber",
"min": 0,
"definition": "A list of note references to the notes provided below.",
"isModifier": false,
"short": "List of note numbers which apply",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.noteNumber"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail",
"min": 0,
"definition": "Second tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Group or type of product or service",
"comments": "ItemType.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.service",
"min": 1,
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Additional item codes",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.quantity"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Total additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Detail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "DetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail",
"min": 0,
"definition": "Third tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Type of product or service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"min": 1,
"definition": "The fee for an addittional service or product or charge.",
"isModifier": false,
"short": "Additional item codes",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Net additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "SubDetail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis",
"min": 0,
"definition": "The materials and placement date of prior fixed prosthesis.",
"isModifier": false,
"short": "Prosthetic details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.prosthesis.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.item.prosthesis.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.initial",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"isModifier": false,
"short": "Is this the initial service",
"mapping": [ {
"map": "F15/F18 Only for Denture, Crown, Bridge",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.initial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.priorDate",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Date of the initial placement.",
"isModifier": false,
"short": "Initial service Date",
"mapping": [ {
"map": "F04/F19",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.priorDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.priorMaterial",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"isModifier": false,
"short": "Prosthetic Material",
"mapping": [ {
"map": "F20/F21",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.priorMaterial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem",
"min": 0,
"definition": "The first tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.sequenceLinkId",
"min": 0,
"definition": "List of input service items which this service line is intended to replace.",
"isModifier": false,
"short": "Service instances",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.sequenceLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.service",
"min": 1,
"definition": "A code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Group, Service or Product",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.fee",
"min": 0,
"definition": "The fee charged for the professional service or product..",
"isModifier": false,
"short": "Professional fee or Product charge",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.fee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.noteNumberLinkId",
"min": 0,
"definition": "A list of note references to the notes provided below.",
"isModifier": false,
"short": "List of note numbers which apply",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.noteNumberLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Added items adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail",
"min": 0,
"definition": "The second tier service adjudications for payor added services.",
"isModifier": false,
"short": "Added items details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.service",
"min": 1,
"definition": "A code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Service or Product",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.fee",
"min": 0,
"definition": "The fee charged for the professional service or product..",
"isModifier": false,
"short": "Professional fee or Product charge",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.fee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Added items detail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.detail.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.addItem.detail.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"isModifier": false,
"short": "Only if type = oral",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.missingTeeth.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.missingTeeth.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.tooth",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"definition": "The code identifying which tooth is missing.",
"isModifier": false,
"short": "Tooth Code",
"mapping": [ {
"map": "F23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.tooth"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.reason",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"definition": "Missing reason may be: E-extraction, O-other.",
"isModifier": false,
"short": "Reason for missing",
"mapping": [ {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.extractionDate",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"definition": "The date of the extraction either known from records or patient reported estimate.",
"isModifier": false,
"short": "Date of Extraction",
"mapping": [ {
"map": "F24",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.extractionDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.totalCost",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"definition": "The total cost of the services reported.",
"isModifier": false,
"short": "Total Cost of service from the Claim",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalCost"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.unallocDeductable",
"min": 0,
"definition": "The amount of deductable applied which was not allocated to any particular service line.",
"isModifier": false,
"short": "Unallocated deductable",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.unallocDeductable"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.totalBenefit",
"min": 0,
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).",
"isModifier": false,
"short": "Total benefit payable for the Claim",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalBenefit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAdjustment",
"min": 0,
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"isModifier": false,
"short": "Payment adjustment for non-Claim issues",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAdjustment"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAdjustmentReason",
"min": 0,
"definition": "Reason for the payment adjustment.",
"isModifier": false,
"short": "Reason for Payment adjustment",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAdjustmentReason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentDate",
"min": 0,
"definition": "Estimated payment data.",
"isModifier": false,
"short": "Expected data of Payment",
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAmount",
"min": 0,
"definition": "Payable less any payment adjustment.",
"isModifier": false,
"short": "Payment amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAmount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentRef",
"min": 0,
"definition": "Payment identifer.",
"isModifier": false,
"short": "Payment identifier",
"mapping": [ {
"map": "G01, B.23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentRef"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.reserved",
"min": 0,
"definition": "Status of funds reservation (For provider, for Patient, None).",
"isModifier": false,
"short": "Funds reserved status",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.reserved"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"isModifier": false,
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.form"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note",
"min": 0,
"definition": "Note text.",
"isModifier": false,
"short": "Processing notes",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Notes"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.note"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.note.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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "ExplanationOfBenefit.note.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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.number",
"min": 0,
"definition": "An integer associated with each note which may be referred to from each service line item.",
"isModifier": false,
"short": "Note Number for this note",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.number"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.type",
"min": 0,
"definition": "The note purpose: Print/Display.",
"isModifier": false,
"short": "display | print | printoper",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.text",
"min": 0,
"definition": "The note text.",
"isModifier": false,
"short": "Note explanitory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.text"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance",
"min": 0,
"definition": "Balance by Benefit Category.",
"isModifier": false,
"short": "Balance by Benefit Category",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.category",
"min": 1,
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"isModifier": false,
"short": "Benefit Category",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"min": 0,
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"isModifier": false,
"short": "Benefit SubCategory",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.subCategory"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.network",
"min": 0,
"definition": "Network designation.",
"isModifier": false,
"short": "In or out of network",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.network"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.unit",
"min": 0,
"definition": "Unit designation: individual or family.",
"isModifier": false,
"short": "Individual or family",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.unit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.term",
"min": 0,
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"isModifier": false,
"short": "Annual or lifetime",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.term"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial",
"min": 0,
"definition": "Benefits Used to date.",
"isModifier": false,
"short": "Benefit Summary",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references).",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"representation": [ "xmlAttr" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"min": 1,
"definition": "Deductable, visits, benefit amount.",
"isModifier": false,
"short": "Deductable, visits, benefit amount",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]",
"min": 0,
"definition": "Benefits allowed.",
"isModifier": false,
"short": "Benefits allowed",
"type": [ {
"code": "unsignedInt"
}, {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]",
"min": 0,
"definition": "Benefits used.",
"isModifier": false,
"short": "Benefits used",
"type": [ {
"code": "unsignedInt"
}, {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]"
},
"isSummary": true
} ]
},
"status": "draft",
"id": "fed27d56-f5cd-480b-98b2-15b74b1f2ca8",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit",
"version": null,
"differential": {
"element": [ {
"path": "ExplanationOfBenefit",
"min": 0,
"definition": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"isModifier": false,
"short": "Explanation of Benefit resource",
"mapping": [ {
"map": "financial.other",
"identity": "w5"
} ],
"mustSupport": false,
"alias": [ "EOB" ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.identifier",
"min": 0,
"definition": "The Response Business Identifier.",
"isModifier": false,
"short": "Business Identifier",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.identifier"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.claim[x]",
"min": 0,
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"isModifier": false,
"short": "Claim reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claim[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.claimResponse[x]",
"min": 0,
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"isModifier": false,
"short": "Claim response reference",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.claimResponse[x]"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Finer grained claim type information",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.subType"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.ruleset",
"min": 0,
"definition": "The version of the specification on which this instance relies.",
"isModifier": false,
"short": "Current specification followed",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"alias": [ "BusinessVersion" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.ruleset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.originalRuleset",
"min": 0,
"definition": "The version of the specification from which the original instance was created.",
"isModifier": false,
"short": "Original specification followed",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"alias": [ "OriginalBusinessVersion" ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalRuleset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.created",
"min": 0,
"definition": "The date when the EOB was created.",
"isModifier": false,
"short": "Creation date",
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.created"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.billablePeriod",
"min": 0,
"definition": "The billable period for which charges are being submitted.",
"isModifier": false,
"short": "Period for charge submission",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.billablePeriod"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.disposition",
"min": 0,
"definition": "A description of the status of the adjudication.",
"isModifier": false,
"short": "Disposition Message",
"comments": "Do we need a disposition code?",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.disposition"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.provider[x]",
"min": 0,
"definition": "The provider which is responsible for the claim.",
"isModifier": false,
"short": "Responsible provider for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.provider[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.organization[x]",
"min": 0,
"definition": "The provider which is responsible for the claim.",
"isModifier": false,
"short": "Responsible organization for the claim",
"mapping": [ {
"map": "B02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.organization[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.facility[x]",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing Facility",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.facility[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"isModifier": false,
"short": "Related Claims which may be revelant to processing this claimn",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaims"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.related"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.claim[x]",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"isModifier": false,
"short": "Reference to the related claim",
"comments": "Do we need a relationship code?",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.claim[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.relationship",
"min": 0,
"definition": "For example prior or umbrella.",
"isModifier": false,
"short": "How the reference claim is related",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.relationship"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.related.reference",
"min": 0,
"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 # .",
"isModifier": false,
"short": "Related file or case reference",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.related.reference"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.prescription[x]",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"isModifier": false,
"short": "Prescription",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/MedicationOrder" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.prescription[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.originalPrescription[x]",
"min": 0,
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.",
"isModifier": false,
"short": "Original Prescription",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/MedicationOrder" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.originalPrescription[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee",
"min": 0,
"definition": "The party to be reimbursed for the services.",
"isModifier": false,
"short": "Payee",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee.type",
"min": 0,
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"short": "Type of party: Subscriber, Provider, other",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.payee.party[x]",
"min": 0,
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"short": "Party to receive the payable",
"mapping": [ {
"map": "B03, B04",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.payee.party[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.referral[x]",
"min": 0,
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"isModifier": false,
"short": "Treatment Referral",
"mapping": [ {
"map": "B05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/ReferralRequest" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.referral[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.occurrenceCode",
"min": 0,
"definition": "**Insert definition of Occurrence codes.",
"isModifier": false,
"short": "Occurrence Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Occurrence codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/occurrence-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.occurrenceCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.occurenceSpanCode",
"min": 0,
"definition": "**Insert definition of Occurrence Span codes.",
"isModifier": false,
"short": "Occurrence Span Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Occurrence Span codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/occurrence-span-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.occurenceSpanCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.valueCode",
"min": 0,
"definition": "**Insert definition of Value codes.",
"isModifier": false,
"short": "Value Codes",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Value code",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/value-codes"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.valueCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis",
"min": 0,
"definition": "Ordered list of patient diagnosis for which care is sought.",
"isModifier": false,
"short": "Diagnosis",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis.sequence",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"isModifier": false,
"short": "Number to covey order of diagnosis",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.diagnosis.diagnosis",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"definition": "The diagnosis.",
"isModifier": false,
"short": "Patient's list of diagnosis",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.diagnosis.diagnosis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure",
"min": 0,
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"isModifier": false,
"short": "Procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.procedure"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.sequence",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"definition": "Sequence of procedures which serves to order and provide a link.",
"isModifier": false,
"short": "Procedure sequence for reference",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.date",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"definition": "Date and optionally time the procedure was performed .",
"isModifier": false,
"short": "When the procedure was performed",
"comments": "SB DateTime??",
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.date"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"definition": "The procedure code.",
"isModifier": false,
"short": "Patient's list of procedures performed",
"type": [ {
"code": "Coding"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.procedure.procedure[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.specialCondition",
"min": 0,
"definition": "List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"isModifier": false,
"short": "List of special Conditions",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.specialCondition"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.patient[x]",
"min": 1,
"definition": "Patient Resource.",
"isModifier": false,
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "C06,C07,C08, C05, C04",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.patient[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.precedence",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Precedence (primary, secondary, etc.).",
"isModifier": false,
"short": "Precedence (primary, secondary, etc.)",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.precedence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 1,
"definition": "Financial instrument by which payment information for health care.",
"isModifier": false,
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.coverage"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage.coverage[x]",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"definition": "Reference to the program or plan identification, underwriter or payor.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.coverage.coverage[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.coverage.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.",
"isModifier": false,
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.coverage.preAuthRef"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentDate",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"definition": "Date of an accident which these services are addressing.",
"isModifier": false,
"short": "When the accident occurred",
"mapping": [ {
"map": "F02",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentType",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "Type of accident: work, auto, etc.",
"isModifier": false,
"short": "The nature of the accident",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentType"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.accidentLocation[x]",
"min": 0,
"definition": "Accident Place.",
"isModifier": false,
"short": "Accident Place",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.accidentLocation[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.interventionException",
"requirements": "Coverage may be modified based on exception information provided.",
"min": 0,
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"isModifier": false,
"short": "Intervention and exception code (Pharma)",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Intervention and exception codes (Pharm)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.interventionException"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset",
"min": 0,
"definition": "Period, start and last dates of aspects of the Condition or related services.",
"isModifier": false,
"short": "Condition related Onset related dates and codes",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Onset"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.onset"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset.time[x]",
"min": 0,
"definition": "The start or start and end dates for the treatable condition.",
"isModifier": false,
"short": "Illness, injury or treatable condition date",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.onset.time[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.onset.type",
"min": 0,
"definition": "Onset typifications eg. Start of pregnancy, start of illnes, etc.",
"isModifier": false,
"short": "Onset of what",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Condition related start, end and period codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-onsettype"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.onset.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.employmentImpacted",
"min": 0,
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"isModifier": false,
"short": "Period unable to work",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.employmentImpacted"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.hospitalization",
"min": 0,
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"isModifier": false,
"short": "Period in hospital",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.hospitalization"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item",
"min": 0,
"definition": "First tier of goods and services.",
"isModifier": false,
"short": "Goods and Services",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Group or type of product or service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.provider[x]",
"min": 0,
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"isModifier": false,
"short": "Responsible practitioner",
"mapping": [ {
"map": "24G&H not sure",
"identity": "rim"
}, {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.provider[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.supervisor[x]",
"min": 0,
"definition": "The practitioner who is supervising the work of the servicing provider(s).",
"isModifier": false,
"short": "Supervising Practitioner",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.supervisor[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.providerQualification",
"min": 0,
"definition": "The qualification which is applicable for this service.",
"isModifier": false,
"short": "Type, classification or Specialization",
"mapping": [ {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.providerQualification"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.diagnosisLinkId",
"min": 0,
"definition": "Diagnosis applicable for this service or product line.",
"isModifier": false,
"short": "Applicable diagnoses",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.diagnosisLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.service",
"min": 1,
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Item Code",
"mapping": [ {
"map": "F06",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.serviceModifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Unusual circumstances which may influence adjudication.",
"isModifier": false,
"short": "Service/Product modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Factors which may influce adjudication of services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-modifiers"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.serviceModifier"
},
"isSummary": true
}, {
"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 an appliance was lost or stolen.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "F16 (required field for Oral) and F05",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"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": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.modifier"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.serviced[x]",
"min": 0,
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"isModifier": false,
"short": "Date or dates of Service",
"mapping": [ {
"map": "F09",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.serviced[x]"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.place",
"min": 0,
"definition": "Where the service was provided.",
"isModifier": false,
"short": "Place of service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.place"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.quantity"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.unitPrice",
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F12",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.bodySite",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc).",
"isModifier": false,
"short": "Service Location",
"mapping": [ {
"map": "F10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.bodySite"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.subSite",
"min": 0,
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"isModifier": false,
"short": "Service Sub-location",
"mapping": [ {
"map": "F11",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.subSite"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.noteNumber",
"min": 0,
"definition": "A list of note references to the notes provided below.",
"isModifier": false,
"short": "List of note numbers which apply",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.noteNumber"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail",
"min": 0,
"definition": "Second tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Group or type of product or service",
"comments": "ItemType.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.service",
"min": 1,
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Additional item codes",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
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"min": 0,
"path": "ExplanationOfBenefit.item.detail.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.quantity"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Total additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Detail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "DetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail",
"min": 0,
"definition": "Third tier of goods and services.",
"isModifier": false,
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"min": 1,
"definition": "A service line number.",
"isModifier": false,
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.type",
"min": 1,
"definition": "The type of product or service.",
"isModifier": false,
"short": "Type of product or service",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"min": 1,
"definition": "The fee for an addittional service or product or charge.",
"isModifier": false,
"short": "Additional item codes",
"mapping": [ {
"map": "F34/F35",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"isModifier": false,
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of Products or Services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Price scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.factor"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.points",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"isModifier": false,
"short": "Difficulty scaling factor",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.points"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Net additional item cost",
"mapping": [ {
"map": "F13/F14",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.net"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.udi"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "SubDetail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis",
"min": 0,
"definition": "The materials and placement date of prior fixed prosthesis.",
"isModifier": false,
"short": "Prosthetic details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
} ],
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.initial",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"isModifier": false,
"short": "Is this the initial service",
"mapping": [ {
"map": "F15/F18 Only for Denture, Crown, Bridge",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.initial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.priorDate",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Date of the initial placement.",
"isModifier": false,
"short": "Initial service Date",
"mapping": [ {
"map": "F04/F19",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.priorDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.item.prosthesis.priorMaterial",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"isModifier": false,
"short": "Prosthetic Material",
"mapping": [ {
"map": "F20/F21",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.item.prosthesis.priorMaterial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem",
"min": 0,
"definition": "The first tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.sequenceLinkId",
"min": 0,
"definition": "List of input service items which this service line is intended to replace.",
"isModifier": false,
"short": "Service instances",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.sequenceLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.service",
"min": 1,
"definition": "A code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Group, Service or Product",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.fee",
"min": 0,
"definition": "The fee charged for the professional service or product..",
"isModifier": false,
"short": "Professional fee or Product charge",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.fee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.noteNumberLinkId",
"min": 0,
"definition": "A list of note references to the notes provided below.",
"isModifier": false,
"short": "List of note numbers which apply",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.noteNumberLinkId"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Added items adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail",
"min": 0,
"definition": "The second tier service adjudications for payor added services.",
"isModifier": false,
"short": "Added items details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
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"base": {
"max": "*",
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"path": "ExplanationOfBenefit.addItem.detail"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.service",
"min": 1,
"definition": "A code to indicate the Professional Service or Product supplied.",
"isModifier": false,
"short": "Service or Product",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"maxLength": 0,
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"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.service"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.fee",
"min": 0,
"definition": "The fee charged for the professional service or product..",
"isModifier": false,
"short": "Professional fee or Product charge",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.fee"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication",
"min": 0,
"definition": "The adjudications results.",
"isModifier": false,
"short": "Added items detail adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetailAdjudication"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.category",
"min": 1,
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"isModifier": false,
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.reason",
"min": 0,
"definition": "Adjudication reason such as limit reached.",
"isModifier": false,
"short": "Adjudication reason",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.amount",
"min": 0,
"definition": "Monitory amount associated with the code.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.amount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.addItem.detail.adjudication.value",
"min": 0,
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monitory value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.addItem.detail.adjudication.value"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"isModifier": false,
"short": "Only if type = oral",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.tooth",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"definition": "The code identifying which tooth is missing.",
"isModifier": false,
"short": "Tooth Code",
"mapping": [ {
"map": "F23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.tooth"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.reason",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"definition": "Missing reason may be: E-extraction, O-other.",
"isModifier": false,
"short": "Reason for missing",
"mapping": [ {
"map": "not used",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.reason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.missingTeeth.extractionDate",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"definition": "The date of the extraction either known from records or patient reported estimate.",
"isModifier": false,
"short": "Date of Extraction",
"mapping": [ {
"map": "F24",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.missingTeeth.extractionDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.totalCost",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"definition": "The total cost of the services reported.",
"isModifier": false,
"short": "Total Cost of service from the Claim",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalCost"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.unallocDeductable",
"min": 0,
"definition": "The amount of deductable applied which was not allocated to any particular service line.",
"isModifier": false,
"short": "Unallocated deductable",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.unallocDeductable"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.totalBenefit",
"min": 0,
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).",
"isModifier": false,
"short": "Total benefit payable for the Claim",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.totalBenefit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAdjustment",
"min": 0,
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"isModifier": false,
"short": "Payment adjustment for non-Claim issues",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAdjustment"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAdjustmentReason",
"min": 0,
"definition": "Reason for the payment adjustment.",
"isModifier": false,
"short": "Reason for Payment adjustment",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAdjustmentReason"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentDate",
"min": 0,
"definition": "Estimated payment data.",
"isModifier": false,
"short": "Expected data of Payment",
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentDate"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentAmount",
"min": 0,
"definition": "Payable less any payment adjustment.",
"isModifier": false,
"short": "Payment amount",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/Money" ]
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentAmount"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.paymentRef",
"min": 0,
"definition": "Payment identifer.",
"isModifier": false,
"short": "Payment identifier",
"mapping": [ {
"map": "G01, B.23",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.paymentRef"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.reserved",
"min": 0,
"definition": "Status of funds reservation (For provider, for Patient, None).",
"isModifier": false,
"short": "Funds reserved status",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.reserved"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"isModifier": false,
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.form"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note",
"min": 0,
"definition": "Note text.",
"isModifier": false,
"short": "Processing notes",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Notes"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.note"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.number",
"min": 0,
"definition": "An integer associated with each note which may be referred to from each service line item.",
"isModifier": false,
"short": "Note Number for this note",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.number"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.type",
"min": 0,
"definition": "The note purpose: Print/Display.",
"isModifier": false,
"short": "display | print | printoper",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.type"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.note.text",
"min": 0,
"definition": "The note text.",
"isModifier": false,
"short": "Note explanitory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.note.text"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance",
"min": 0,
"definition": "Balance by Benefit Category.",
"isModifier": false,
"short": "Balance by Benefit Category",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.category",
"min": 1,
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"isModifier": false,
"short": "Benefit Category",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.category"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"min": 0,
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"isModifier": false,
"short": "Benefit SubCategory",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.subCategory"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.network",
"min": 0,
"definition": "Network designation.",
"isModifier": false,
"short": "In or out of network",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.network"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.unit",
"min": 0,
"definition": "Unit designation: individual or family.",
"isModifier": false,
"short": "Individual or family",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.unit"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.term",
"min": 0,
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"isModifier": false,
"short": "Annual or lifetime",
"type": [ {
"code": "Coding"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
},
"max": "1",
"maxLength": 0,
"base": {
"max": "1",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.term"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial",
"min": 0,
"definition": "Benefits Used to date.",
"isModifier": false,
"short": "Benefit Summary",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
} ],
"max": "*",
"maxLength": 0,
"base": {
"max": "*",
"min": 0,
"path": "ExplanationOfBenefit.benefitBalance.financial"
},
"isSummary": true
}, {
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"min": 1,
"definition": "Deductable, visits, benefit amount.",
"isModifier": false,
"short": "Deductable, visits, benefit amount",
"type": [ {
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