<status value="active" /> <experimental value="false" /> <description value="A profile on the EOB resources that allows providing information about potentially duplicate receipts as part of a ClaimResponse" /> <fhirVersion value="5.0.0" /> <mapping> <identity value="BPCS" /> <name value="Internal BPCS API" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="ExplanationOfBenefit" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit" /> <derivation value="constraint" /> <differential> <element id="ExplanationOfBenefit.id"> <path value="ExplanationOfBenefit.id" /> <comment value="Used to point to the receipt collection from the relevant ClaimResponseItem" /> <min value="1" /> <patternId value="dups" /> </element> <element id="ExplanationOfBenefit.status"> <path value="ExplanationOfBenefit.status" /> <patternCode value="active" /> </element> <element id="ExplanationOfBenefit.type"> <path value="ExplanationOfBenefit.type" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type" /> <code value="pharmacy" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.use"> <path value="ExplanationOfBenefit.use" /> <patternCode value="claim" /> </element> <element id="ExplanationOfBenefit.patient"> <path value="ExplanationOfBenefit.patient" /> <type> <code value="Reference" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Reference-group-or-patient" /> <targetProfile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Patient-search" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.created"> <path value="ExplanationOfBenefit.created" /> <comment value="This will be the date/time the ClaimResponse was returned" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurer"> <path value="ExplanationOfBenefit.insurer" /> <patternReference> <reference value="Organization/bpcs" /> </patternReference> </element> <element id="ExplanationOfBenefit.outcome"> <path value="ExplanationOfBenefit.outcome" /> <patternCode value="complete" /> </element> <element id="ExplanationOfBenefit.supportingInfo"> <path value="ExplanationOfBenefit.supportingInfo" /> <slicing> <discriminator> <type value="type" /> <path value="category" /> </discriminator> <discriminator> <type value="type" /> <path value="value" /> </discriminator> <discriminator> <type value="profile" /> <path value="value.resolve()" /> </discriminator> <rules value="open" /> </slicing> <comment value="There will be at least one supportingInformation for each receipt containing the dispense information associated with that receipt" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo:dispense"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="dispense" /> <comment value="Pointed to by item.informationSequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo:dispense.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" /> <code value="info" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:dispense.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <min value="1" /> <type> <code value="Reference" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Reference-rest" /> <targetProfile value="https://bpcs.exchange/fhir/StructureDefinition/profile-MedicationDispense" /> <aggregation value="contained" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item"> <path value="ExplanationOfBenefit.item" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.extension"> <path value="ExplanationOfBenefit.item.extension" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.extension:patient"> <path value="ExplanationOfBenefit.item.extension" /> <sliceName value="patient" /> <comment value="This will only be present if the search was performed on a family rather than an individual recipient" /> <type> <code value="Extension" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient" /> </type> <condition value="BPCS-EOB-1a" /> <condition value="BPCS-EOB-1b" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.extension:duplicateVersion"> <path value="ExplanationOfBenefit.item.extension" /> <sliceName value="duplicateVersion" /> <type> <code value="Extension" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.extension:insurancePlan"> <path value="ExplanationOfBenefit.item.extension" /> <sliceName value="insurancePlan" /> <min value="1" /> <type> <code value="Extension" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.extension:deductibleStatus"> <path value="ExplanationOfBenefit.item.extension" /> <sliceName value="deductibleStatus" /> <comment value="This will only be present for Trillium pre-registration claims" /> <type> <code value="Extension" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-DeductibleStatus" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.sequence"> <path value="ExplanationOfBenefit.item.sequence" /> <comment value="The sequence number here won't necessarily be the same as it was in the original claim" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.informationSequence"> <path value="ExplanationOfBenefit.item.informationSequence" /> <comment value="This will, at minimum point to the the dispense associated with the duplicate receipt" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService"> <path value="ExplanationOfBenefit.item.productOrService" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding"> <path value="ExplanationOfBenefit.item.productOrService.coding" /> <slicing> <discriminator> <type value="value" /> <path value="system" /> </discriminator> <rules value="open" /> </slicing> <min value="2" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:claimDinPin"> <path value="ExplanationOfBenefit.item.productOrService.coding" /> <sliceName value="claimDinPin" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:claimDinPin.system"> <path value="ExplanationOfBenefit.item.productOrService.coding.system" /> <min value="1" /> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://bpcs.exchange/fhir/ValueSet/vs-DinPinSystem" /> </binding> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:claimDinPin.code"> <path value="ExplanationOfBenefit.item.productOrService.coding.code" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.dinPin" /> </mapping> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:claimDinPin.display"> <path value="ExplanationOfBenefit.item.productOrService.coding.display" /> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.dinDesc" /> </mapping> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:generic"> <path value="ExplanationOfBenefit.item.productOrService.coding" /> <sliceName value="generic" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:generic.system"> <path value="ExplanationOfBenefit.item.productOrService.coding.system" /> <min value="1" /> <patternUri value="http://terminology.hl7.org/CodeSystem/hc-CCDD" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:generic.display"> <path value="ExplanationOfBenefit.item.productOrService.coding.display" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.genName" /> </mapping> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:dummyPIN"> <path value="ExplanationOfBenefit.item.productOrService.coding" /> <sliceName value="dummyPIN" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:dummyPIN.system"> <path value="ExplanationOfBenefit.item.productOrService.coding.system" /> <min value="1" /> <patternUri value="https://bpcs.exchange/fhir/CodeSystem/cs-DummyPIN" /> </element> <element id="ExplanationOfBenefit.item.productOrService.coding:dummyPIN.display"> <path value="ExplanationOfBenefit.item.productOrService.coding.display" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DrugDTO.dummyPIN" /> </mapping> </element> <element id="ExplanationOfBenefit.item.modifier"> <path value="ExplanationOfBenefit.item.modifier" /> <slicing> <discriminator> <type value="value" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://bpcs.exchange/fhir/ValueSet/vs-ClaimResponse-AllowedModifier" /> </binding> </element> <element id="ExplanationOfBenefit.item.modifier:medicalReason"> <path value="ExplanationOfBenefit.item.modifier" /> <sliceName value="medicalReason" /> <short value="Medical reason" /> <max value="1" /> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://bpcs.exchange/fhir/ValueSet/vs-MedicalReason" /> </binding> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.medCond, ReceiptDTO.medCond" /> </mapping> </element> <element id="ExplanationOfBenefit.item.patientPaid"> <path value="ExplanationOfBenefit.item.patientPaid" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="Net - ReceiptDTO.prevPd (drug submitted + fee submitted - patientPaid)" /> </mapping> </element> <element id="ExplanationOfBenefit.item.reviewOutcome"> <path value="ExplanationOfBenefit.item.reviewOutcome" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.reviewOutcome.decision"> <path value="ExplanationOfBenefit.item.reviewOutcome.decision" /> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://bpcs.exchange/fhir/ValueSet/vs-Receipt-status" /> </binding> <mapping> <identity value="BPCS" /> <map value="ReceiptDTO.currStat (denied=R, paid=P, pending=H, reversed=V, acceptedReversed=C)" /> </mapping> </element> <element id="ExplanationOfBenefit.item.adjudication"> <path value="ExplanationOfBenefit.item.adjudication" /> <slicing> <discriminator> <type value="value" /> <path value="category" /> </discriminator> <rules value="open" /> </slicing> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="benefit" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="benefit" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.totAmtPd" /> </mapping> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="deductible" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="deductible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="ReceiptDTO.deductToCollect" /> </mapping> </element> <element id="ExplanationOfBenefit.item.detail"> <path value="ExplanationOfBenefit.item.detail" /> <slicing> <discriminator> <type value="value" /> <path value="productOrService" /> </discriminator> <rules value="open" /> </slicing> </element> <element id="ExplanationOfBenefit.item.detail:drugCost"> <path value="ExplanationOfBenefit.item.detail" /> <sliceName value="drugCost" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.sequence"> <path value="ExplanationOfBenefit.item.detail.sequence" /> <comment value="A unique number within the scope of the item. Typically '1'." /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.productOrService"> <path value="ExplanationOfBenefit.item.detail.productOrService" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" /> <code value="drugCost" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <slicing> <discriminator> <type value="value" /> <path value="category" /> </discriminator> <rules value="open" /> </slicing> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:submitted"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <sliceName value="submitted" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:submitted.category"> <path value="ExplanationOfBenefit.item.detail.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="submitted" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:submitted.amount"> <path value="ExplanationOfBenefit.item.detail.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.inputTotal" /> </mapping> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:eligible"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <sliceName value="eligible" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:eligible.category"> <path value="ExplanationOfBenefit.item.detail.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="eligible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:drugCost.adjudication:eligible.amount"> <path value="ExplanationOfBenefit.item.detail.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.outputTotal" /> </mapping> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee"> <path value="ExplanationOfBenefit.item.detail" /> <sliceName value="pharmacistFee" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.sequence"> <path value="ExplanationOfBenefit.item.detail.sequence" /> <comment value="A unique number within the scope of the item. Typically '2'." /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.productOrService"> <path value="ExplanationOfBenefit.item.detail.productOrService" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" /> <code value="pharmacistFee" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <slicing> <discriminator> <type value="value" /> <path value="category" /> </discriminator> <rules value="open" /> </slicing> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:submitted"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <sliceName value="submitted" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:submitted.category"> <path value="ExplanationOfBenefit.item.detail.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="submitted" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:submitted.amount"> <path value="ExplanationOfBenefit.item.detail.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.fee" /> </mapping> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:eligible"> <path value="ExplanationOfBenefit.item.detail.adjudication" /> <sliceName value="eligible" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:eligible.category"> <path value="ExplanationOfBenefit.item.detail.adjudication.category" /> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="eligible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.detail:pharmacistFee.adjudication:eligible.amount"> <path value="ExplanationOfBenefit.item.detail.adjudication.amount" /> <min value="1" /> <type> <code value="Money" /> <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-Money-CAD" /> </type> <mustSupport value="true" /> <mapping> <identity value="BPCS" /> <map value="DuplicateClaimDTO.alldFee" /> </mapping> </element> </differential> </StructureDefinition>