{ "resourceType": "StructureDefinition", "id": "profile-ExplanationOfBenefit-expenses-quarterly", "url": "https://bpcs.exchange/fhir/StructureDefinition/profile-ExplanationOfBenefit-expenses-quarterly", "name": "ExplanationOfBenefitExpensesQuarterly", "title": "Recipient Quarterly Expenses", "status": "active", "experimental": false, "description": "A profile on the EOB resources that allows reporting the total of eligible expenses for a quarter", "fhirVersion": "5.0.0", "mapping": [ { "identity": "BPCS", "name": "Internal BPCS API" } ], "kind": "resource", "abstract": false, "type": "ExplanationOfBenefit", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit", "derivation": "constraint", "snapshot": { "element": [ { "id": "ExplanationOfBenefit", "path": "ExplanationOfBenefit", "short": "Explanation of Benefit resource", "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.", "alias": [ "EOB" ], "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource", "expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" } ], "mustSupport": false, "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "Entity, Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "w5", "map": "financial.other" } ] }, { "id": "ExplanationOfBenefit.id", "path": "ExplanationOfBenefit.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "This id will always be a random UUID, which will change each time a query is done - because the calculation is performed anew each time", "min": 1, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mustSupport": true, "isModifier": false, "isSummary": true }, { "id": "ExplanationOfBenefit.meta", "path": "ExplanationOfBenefit.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.implicitRules", "path": "ExplanationOfBenefit.implicitRules", "short": "A set of rules under which this content was created", "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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.", "comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.language", "path": "ExplanationOfBenefit.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "required", "description": "IETF language tag for a human language", "valueSet": "http://hl7.org/fhir/ValueSet/all-languages|5.0.0", "additional": [ { "purpose": "starter", "valueSet": "http://hl7.org/fhir/ValueSet/languages" } ] }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.text", "path": "ExplanationOfBenefit.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource and can 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.", "comment": "Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "dom-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "ExplanationOfBenefit.contained", "path": "ExplanationOfBenefit.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.", "comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "condition": [ "dom-2", "dom-4", "dom-3", "dom-5" ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.extension", "path": "ExplanationOfBenefit.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.modifierExtension", "path": "ExplanationOfBenefit.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.identifier", "path": "ExplanationOfBenefit.identifier", "short": "Business Identifier for the resource", "definition": "A unique identifier assigned to this explanation of benefit.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows EOBs to be distinguished and referenced.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" } ] }, { "id": "ExplanationOfBenefit.traceNumber", "path": "ExplanationOfBenefit.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.status", "path": "ExplanationOfBenefit.status", "short": "active | cancelled | draft | entered-in-error", "definition": "The status of the resource instance.", "comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.", "requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "patternCode": "active", "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ExplanationOfBenefitStatus" } ], "strength": "required", "description": "A code specifying the state of the resource instance.", "valueSet": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" } ] }, { "id": "ExplanationOfBenefit.type", "path": "ExplanationOfBenefit.type", "short": "Category or discipline", "definition": "The category of claim, e.g. oral, pharmacy, vision, institutional, professional.", "comment": "The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.", "requirements": "Claim type determine the general sets of business rules applied for information requirements and adjudication.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.type", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "patternCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClaimType" } ], "strength": "extensible", "description": "The type or discipline-style of the claim.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.class" } ] }, { "id": "ExplanationOfBenefit.subType", "path": "ExplanationOfBenefit.subType", "short": "More granular claim type", "definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.", "comment": "This may contain the local bill type codes such as the US UB-04 bill type code.", "requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.subType", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClaimSubType" } ], "strength": "example", "description": "A more granular claim typecode.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" } ] }, { "id": "ExplanationOfBenefit.use", "path": "ExplanationOfBenefit.use", "short": "claim | preauthorization | predetermination", "definition": "A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "requirements": "This element is required to understand the nature of the request for adjudication.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.use", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "patternCode": "claim", "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Use" } ], "strength": "required", "description": "Complete, proposed, exploratory, other.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-use|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.class" } ] }, { "id": "ExplanationOfBenefit.patient", "path": "ExplanationOfBenefit.patient", "short": "A reference from one resource to another", "definition": "A reference from one resource to another.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.patient", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-Reference-rest" ], "targetProfile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-Patient-search" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "BPCS", "map": "RecipientExpensesDTO.odbNum" } ] }, { "id": "ExplanationOfBenefit.billablePeriod", "path": "ExplanationOfBenefit.billablePeriod", "short": "Relevant time frame for the claim", "definition": "The period for which charges are being submitted.", "comment": "Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.", "requirements": "A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.billablePeriod", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "w5", "map": "FiveWs.done[x]" } ] }, { "id": "ExplanationOfBenefit.created", "path": "ExplanationOfBenefit.created", "short": "Response creation date", "definition": "The date this resource was created.", "comment": "This will be the date/time the operation was executed", "requirements": "Need to record a timestamp for use by both the recipient and the issuer.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.created", "min": 1, "max": "1" }, "type": [ { "code": "dateTime" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.recorded" } ] }, { "id": "ExplanationOfBenefit.enterer", "path": "ExplanationOfBenefit.enterer", "short": "Author of the claim", "definition": "Individual who created the claim, predetermination or preauthorization.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Some jurisdictions require the contact information for personnel completing claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.enterer", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.agent" }, { "identity": "w5", "map": "FiveWs.author" } ] }, { "id": "ExplanationOfBenefit.insurer", "path": "ExplanationOfBenefit.insurer", "short": "Party responsible for reimbursement", "definition": "The party responsible for authorization, adjudication and reimbursement.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.insurer", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "patternReference": { "reference": "Organization/bpcs" }, "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.agent" }, { "identity": "w5", "map": "FiveWs.author" } ] }, { "id": "ExplanationOfBenefit.provider", "path": "ExplanationOfBenefit.provider", "short": "Party responsible for the claim", "definition": "The provider which is responsible for the claim, predetermination or preauthorization.", "comment": "Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.provider", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.source" } ] }, { "id": "ExplanationOfBenefit.priority", "path": "ExplanationOfBenefit.priority", "short": "Desired processing urgency", "definition": "The provider-required urgency of processing the request. Typical values include: stat, normal deferred.", "comment": "If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.", "requirements": "The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.priority", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcessPriority" } ], "strength": "example", "description": "The timeliness with which processing is required: stat, normal, deferred.", "valueSet": "http://hl7.org/fhir/ValueSet/process-priority" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "Request.priority" } ] }, { "id": "ExplanationOfBenefit.fundsReserveRequested", "path": "ExplanationOfBenefit.fundsReserveRequested", "short": "For whom to reserve funds", "definition": "A code to indicate whether and for whom funds are to be reserved for future claims.", "comment": "This field is only used for preauthorizations.", "requirements": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.", "alias": [ "Fund pre-allocation" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.fundsReserveRequested", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FundsReserve" } ], "strength": "example", "description": "For whom funds are to be reserved: (Patient, Provider, None).", "valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.fundsReserve", "path": "ExplanationOfBenefit.fundsReserve", "short": "Funds reserved status", "definition": "A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.", "comment": "Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.", "requirements": "Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.fundsReserve", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FundsReserve" } ], "strength": "example", "description": "For whom funds are to be reserved: (Patient, Provider, None).", "valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.related", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "RelatedClaim" } ], "path": "ExplanationOfBenefit.related", "short": "Prior or corollary claims", "definition": "Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.", "comment": "For example, for the original treatment and follow-up exams.", "requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.related", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.related.id", "path": "ExplanationOfBenefit.related.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.related.extension", "path": "ExplanationOfBenefit.related.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.related.modifierExtension", "path": "ExplanationOfBenefit.related.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.related.claim", "path": "ExplanationOfBenefit.related.claim", "short": "Reference to the related claim", "definition": "Reference to a related claim.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.related.claim", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.related.relationship", "path": "ExplanationOfBenefit.related.relationship", "short": "How the reference claim is related", "definition": "A code to convey how the claims are related.", "comment": "For example, prior claim or umbrella.", "requirements": "Some insurers need a declaration of the type of relationship.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.related.relationship", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RelatedClaimRelationship" } ], "strength": "example", "description": "Relationship of this claim to a related Claim.", "valueSet": "http://hl7.org/fhir/ValueSet/related-claim-relationship" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.related.reference", "path": "ExplanationOfBenefit.related.reference", "short": "File or case reference", "definition": "An alternate organizational reference to the case or file to which this particular claim pertains.", "comment": "For example, Property/Casualty insurer claim number or Workers Compensation case number.", "requirements": "In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.related.reference", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.prescription", "path": "ExplanationOfBenefit.prescription", "short": "Prescription authorizing services or products", "definition": "Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Required to authorize the dispensing of controlled substances and devices.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.prescription", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.originalPrescription", "path": "ExplanationOfBenefit.originalPrescription", "short": "Original prescription if superceded by fulfiller", "definition": "Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.", "comment": "For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.", "requirements": "Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.originalPrescription", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationRequest" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.event", "path": "ExplanationOfBenefit.event", "short": "Event information", "definition": "Information code for an event with a corresponding date or period.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.event", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.event.id", "path": "ExplanationOfBenefit.event.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.event.extension", "path": "ExplanationOfBenefit.event.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.event.modifierExtension", "path": "ExplanationOfBenefit.event.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.event.type", "path": "ExplanationOfBenefit.event.type", "short": "Specific event", "definition": "A coded event such as when a service is expected or a card printed.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.event.type", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DatesType" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/datestype" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.event.when[x]", "path": "ExplanationOfBenefit.event.when[x]", "short": "Occurance date or period", "definition": "A date or period in the past or future indicating when the event occurred or is expectd to occur.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.event.when[x]", "min": 1, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payee", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Payee" } ], "path": "ExplanationOfBenefit.payee", "short": "Recipient of benefits payable", "definition": "The party to be reimbursed for cost of the products and services according to the terms of the policy.", "comment": "Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.", "requirements": "The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payee", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payee.id", "path": "ExplanationOfBenefit.payee.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payee.extension", "path": "ExplanationOfBenefit.payee.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.payee.modifierExtension", "path": "ExplanationOfBenefit.payee.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.payee.type", "path": "ExplanationOfBenefit.payee.type", "short": "Category of recipient", "definition": "Type of Party to be reimbursed: Subscriber, provider, other.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payee.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "PayeeType" } ], "strength": "example", "description": "A code for the party to be reimbursed.", "valueSet": "http://hl7.org/fhir/ValueSet/payeetype" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.payee.party", "path": "ExplanationOfBenefit.payee.party", "short": "Recipient reference", "definition": "Reference to the individual or organization to whom any payment will be made.", "comment": "Not required if the payee is 'subscriber' or 'provider'.", "requirements": "Need to provide demographics if the payee is not 'subscriber' nor 'provider'.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payee.party", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.referral", "path": "ExplanationOfBenefit.referral", "short": "Treatment Referral", "definition": "The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.", "comment": "The referral resource which lists the date, practitioner, reason and other supporting information.", "requirements": "Some insurers require proof of referral to pay for services or to pay specialist rates for services.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.referral", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.cause" } ] }, { "id": "ExplanationOfBenefit.encounter", "path": "ExplanationOfBenefit.encounter", "short": "Encounters associated with the listed treatments", "definition": "Healthcare encounters related to this claim.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Used in some jurisdictions to link clinical events to claim items.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.encounter", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.facility", "path": "ExplanationOfBenefit.facility", "short": "Servicing Facility", "definition": "Facility where the services were provided.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Insurance adjudication can be dependant on where services were delivered.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.facility", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.location" }, { "identity": "w5", "map": "FiveWs.where[x]" } ] }, { "id": "ExplanationOfBenefit.claim", "path": "ExplanationOfBenefit.claim", "short": "Claim reference", "definition": "The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "To provide a link to the original adjudication request.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.claim", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.why[x]" } ] }, { "id": "ExplanationOfBenefit.claimResponse", "path": "ExplanationOfBenefit.claimResponse", "short": "Claim response reference", "definition": "The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "To provide a link to the original adjudication response.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.claimResponse", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.outcome", "path": "ExplanationOfBenefit.outcome", "short": "queued | complete | error | partial", "definition": "The outcome of the claim, predetermination, or preauthorization processing.", "comment": "The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).", "requirements": "To advise the requestor of an overall processing outcome.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.outcome", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "patternCode": "complete", "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClaimOutcome" } ], "strength": "required", "description": "The result of the claim processing.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.decision", "path": "ExplanationOfBenefit.decision", "short": "Result of the adjudication", "definition": "The result of the claim, predetermination, or preauthorization adjudication.", "comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).", "requirements": "To advise the requestor of the result of the adjudication process.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.decision", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjudicationDecision" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/claim-decision" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.disposition", "path": "ExplanationOfBenefit.disposition", "short": "Disposition Message", "definition": "A human readable description of the status of the adjudication.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "requirements": "Provided for user display.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.disposition", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.preAuthRef", "path": "ExplanationOfBenefit.preAuthRef", "short": "Preauthorization reference", "definition": "Reference from the Insurer which is used in later communications which refers to this adjudication.", "comment": "This value is only present on preauthorization adjudications.", "requirements": "On subsequent claims, the insurer may require the provider to quote this value.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.preAuthRef", "min": 0, "max": "*" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.preAuthRefPeriod", "path": "ExplanationOfBenefit.preAuthRefPeriod", "short": "Preauthorization in-effect period", "definition": "The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.", "comment": "This value is only present on preauthorization adjudications.", "requirements": "On subsequent claims, the insurer may require the provider to quote this value.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.preAuthRefPeriod", "min": 0, "max": "*" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" } ] }, { "id": "ExplanationOfBenefit.diagnosisRelatedGroup", "path": "ExplanationOfBenefit.diagnosisRelatedGroup", "short": "Package billing code", "definition": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.", "comment": "For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.", "requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.diagnosisRelatedGroup", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosisRelatedGroup" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.careTeam", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "CareTeam" } ], "path": "ExplanationOfBenefit.careTeam", "short": "Care Team members", "definition": "The members of the team who provided the products and services.", "requirements": "Common to identify the responsible and supporting practitioners.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.careTeam", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.careTeam.id", "path": "ExplanationOfBenefit.careTeam.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.careTeam.extension", "path": "ExplanationOfBenefit.careTeam.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.careTeam.modifierExtension", "path": "ExplanationOfBenefit.careTeam.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.careTeam.sequence", "path": "ExplanationOfBenefit.careTeam.sequence", "short": "Order of care team", "definition": "A number to uniquely identify care team entries.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.careTeam.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.careTeam.provider", "path": "ExplanationOfBenefit.careTeam.provider", "short": "Practitioner or organization", "definition": "Member of the team who provided the product or service.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Often a regulatory requirement to specify the responsible provider.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.careTeam.provider", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.actor" } ] }, { "id": "ExplanationOfBenefit.careTeam.responsible", "path": "ExplanationOfBenefit.careTeam.responsible", "short": "Indicator of the lead practitioner", "definition": "The party who is billing and/or responsible for the claimed products or services.", "comment": "Responsible might not be required when there is only a single provider listed.", "requirements": "When multiple parties are present it is required to distinguish the lead or responsible individual.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.careTeam.responsible", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.careTeam.role", "path": "ExplanationOfBenefit.careTeam.role", "short": "Function within the team", "definition": "The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.", "comment": "Role might not be required when there is only a single provider listed.", "requirements": "When multiple parties are present it is required to distinguish the roles performed by each member.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.careTeam.role", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CareTeamRole" } ], "strength": "example", "description": "The role codes for the care team members.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-careteamrole" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.careTeam.specialty", "path": "ExplanationOfBenefit.careTeam.specialty", "short": "Practitioner or provider specialization", "definition": "The specialization of the practitioner or provider which is applicable for this service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Need to specify which specialization a practitioner or provider acting under when delivering the product or service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.careTeam.specialty", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProviderQualification" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/provider-qualification" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.supportingInfo", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "SupportingInformation" } ], "path": "ExplanationOfBenefit.supportingInfo", "short": "Supporting information", "definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.", "comment": "Often there are multiple jurisdiction specific valuesets which are required.", "requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.supportingInfo", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.id", "path": "ExplanationOfBenefit.supportingInfo.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.extension", "path": "ExplanationOfBenefit.supportingInfo.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.modifierExtension", "path": "ExplanationOfBenefit.supportingInfo.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.sequence", "path": "ExplanationOfBenefit.supportingInfo.sequence", "short": "Information instance identifier", "definition": "A number to uniquely identify supporting information entries.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.category", "path": "ExplanationOfBenefit.supportingInfo.category", "short": "Classification of the supplied information", "definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.", "comment": "This may contain a category for the local bill type codes.", "requirements": "Required to group or associate information items with common characteristics. For example: admission information or prior treatments.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.category", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "InformationCategory" } ], "strength": "example", "description": "The valuset used for additional information category codes.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-informationcategory" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.code", "path": "ExplanationOfBenefit.supportingInfo.code", "short": "Type of information", "definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.", "comment": "This may contain the local bill type codes such as the US UB-04 bill type code.", "requirements": "Required to identify the kind of additional information.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.code", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "InformationCode" } ], "strength": "example", "description": "The valuset used for additional information codes.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-exception" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.timing[x]", "path": "ExplanationOfBenefit.supportingInfo.timing[x]", "short": "When it occurred", "definition": "The date when or period to which this information refers.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.timing[x]", "min": 0, "max": "1" }, "type": [ { "code": "date" }, { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.value[x]", "path": "ExplanationOfBenefit.supportingInfo.value[x]", "short": "Data to be provided", "definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.", "comment": "Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.", "requirements": "To convey the data content to be provided when the information is more than a simple code or period.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "boolean" }, { "code": "string" }, { "code": "Quantity" }, { "code": "Attachment" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] }, { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.supportingInfo.reason", "path": "ExplanationOfBenefit.supportingInfo.reason", "short": "Explanation for the information", "definition": "Provides the reason in the situation where a reason code is required in addition to the content.", "comment": "For example: the reason for the additional stay, or why a tooth is missing.", "requirements": "Needed when the supporting information has both a date and amount/value and requires explanation.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.supportingInfo.reason", "min": 0, "max": "1" }, "type": [ { "code": "Coding" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "cod-1", "severity": "warning", "human": "A Coding SHOULD NOT have a display unless a code is also present. Computation on Coding.display alone is generally unsafe. Consider using CodeableConcept.text", "expression": "code.exists().not() implies display.exists().not()", "source": "http://hl7.org/fhir/StructureDefinition/Coding" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "MissingReason" } ], "strength": "example", "description": "Reason codes for the missing teeth.", "valueSet": "http://hl7.org/fhir/ValueSet/missing-tooth-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" } ] }, { "id": "ExplanationOfBenefit.diagnosis", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Diagnosis" } ], "path": "ExplanationOfBenefit.diagnosis", "short": "Pertinent diagnosis information", "definition": "Information about diagnoses relevant to the claim items.", "requirements": "Required for the adjudication by provided context for the services and product listed.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.diagnosis", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.diagnosis.id", "path": "ExplanationOfBenefit.diagnosis.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.diagnosis.extension", "path": "ExplanationOfBenefit.diagnosis.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.diagnosis.modifierExtension", "path": "ExplanationOfBenefit.diagnosis.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.diagnosis.sequence", "path": "ExplanationOfBenefit.diagnosis.sequence", "short": "Diagnosis instance identifier", "definition": "A number to uniquely identify diagnosis entries.", "comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.", "requirements": "Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.diagnosis.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.diagnosis.diagnosis[x]", "path": "ExplanationOfBenefit.diagnosis.diagnosis[x]", "short": "Nature of illness or problem", "definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.", "requirements": "Provides health context for the evaluation of the products and/or services.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.diagnosis.diagnosis[x]", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ICD10" } ], "strength": "example", "description": "ICD10 Diagnostic codes.", "valueSet": "http://hl7.org/fhir/ValueSet/icd-10" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.diagnosis.type", "path": "ExplanationOfBenefit.diagnosis.type", "short": "Timing or nature of the diagnosis", "definition": "When the condition was observed or the relative ranking.", "comment": "For example: admitting, primary, secondary, discharge.", "requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.diagnosis.type", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosisType" } ], "strength": "example", "description": "The type of the diagnosis: admitting, principal, discharge.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosistype" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.diagnosis.onAdmission", "path": "ExplanationOfBenefit.diagnosis.onAdmission", "short": "Present on admission", "definition": "Indication of whether the diagnosis was present on admission to a facility.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Many systems need to understand for adjudication if the diagnosis was present a time of admission.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.diagnosis.onAdmission", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DiagnosisOnAdmission" } ], "strength": "example", "description": "Present on admission.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.procedure", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Procedure" } ], "path": "ExplanationOfBenefit.procedure", "short": "Clinical procedures performed", "definition": "Procedures performed on the patient relevant to the billing items with the claim.", "requirements": "The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.procedure", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.procedure.id", "path": "ExplanationOfBenefit.procedure.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.procedure.extension", "path": "ExplanationOfBenefit.procedure.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.procedure.modifierExtension", "path": "ExplanationOfBenefit.procedure.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.procedure.sequence", "path": "ExplanationOfBenefit.procedure.sequence", "short": "Procedure instance identifier", "definition": "A number to uniquely identify procedure entries.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Necessary to provide a mechanism to link to claim details.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.procedure.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.procedure.type", "path": "ExplanationOfBenefit.procedure.type", "short": "Category of Procedure", "definition": "When the condition was observed or the relative ranking.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.procedure.type", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureType" } ], "strength": "example", "description": "Example procedure type codes.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-procedure-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.procedure.date", "path": "ExplanationOfBenefit.procedure.date", "short": "When the procedure was performed", "definition": "Date and optionally time the procedure was performed.", "comment": "UTC offset is allowed for dates and partial dates", "requirements": "Required for auditing purposes.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.procedure.date", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.procedure.procedure[x]", "path": "ExplanationOfBenefit.procedure.procedure[x]", "short": "Specific clinical procedure", "definition": "The code or reference to a Procedure resource which identifies the clinical intervention performed.", "requirements": "This identifies the actual clinical procedure.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.procedure.procedure[x]", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ICD10_Procedures" } ], "strength": "example", "description": "ICD10 Procedure codes.", "valueSet": "http://hl7.org/fhir/ValueSet/icd-10-procedures" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.procedure.udi", "path": "ExplanationOfBenefit.procedure.udi", "short": "Unique device identifier", "definition": "Unique Device Identifiers associated with this line item.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.procedure.udi", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.precedence", "path": "ExplanationOfBenefit.precedence", "short": "Precedence (primary, secondary, etc.)", "definition": "This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Needed to coordinate between multiple EOBs for the same suite of services.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.precedence", "min": 0, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.insurance", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Insurance" } ], "path": "ExplanationOfBenefit.insurance", "short": "Patient insurance information", "definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.", "comment": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.", "requirements": "At least one insurer is required for a claim to be a claim.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.insurance", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "Coverage" } ] }, { "id": "ExplanationOfBenefit.insurance.id", "path": "ExplanationOfBenefit.insurance.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.insurance.extension", "path": "ExplanationOfBenefit.insurance.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.insurance.modifierExtension", "path": "ExplanationOfBenefit.insurance.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.insurance.focal", "path": "ExplanationOfBenefit.insurance.focal", "short": "Coverage to be used for adjudication", "definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.", "comment": "A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.", "requirements": "To identify which coverage in the list is being used to adjudicate this claim.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.insurance.focal", "min": 1, "max": "1" }, "type": [ { "code": "boolean" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.insurance.coverage", "path": "ExplanationOfBenefit.insurance.coverage", "short": "Insurance information", "definition": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.insurance.coverage", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.insurance.preAuthRef", "path": "ExplanationOfBenefit.insurance.preAuthRef", "short": "Prior authorization reference number", "definition": "Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.", "comment": "This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.", "requirements": "Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.insurance.preAuthRef", "min": 0, "max": "*" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.accident", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Accident" } ], "path": "ExplanationOfBenefit.accident", "short": "Details of the event", "definition": "Details of a accident which resulted in injuries which required the products and services listed in the claim.", "requirements": "When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.accident", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.accident.id", "path": "ExplanationOfBenefit.accident.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.accident.extension", "path": "ExplanationOfBenefit.accident.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.accident.modifierExtension", "path": "ExplanationOfBenefit.accident.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.accident.date", "path": "ExplanationOfBenefit.accident.date", "short": "When the incident occurred", "definition": "Date of an accident event related to the products and services contained in the claim.", "comment": "The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.", "requirements": "Required for audit purposes and adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.accident.date", "min": 0, "max": "1" }, "type": [ { "code": "date" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.accident.type", "path": "ExplanationOfBenefit.accident.type", "short": "The nature of the accident", "definition": "The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Coverage may be dependant on the type of accident.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.accident.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AccidentType" } ], "strength": "extensible", "description": "Type of accident: work place, auto, etc.", "valueSet": "http://terminology.hl7.org/ValueSet/v3-ActIncidentCode" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.accident.location[x]", "path": "ExplanationOfBenefit.accident.location[x]", "short": "Where the event occurred", "definition": "The physical location of the accident event.", "requirements": "Required for audit purposes and determination of applicable insurance liability.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.accident.location[x]", "min": 0, "max": "1" }, "type": [ { "code": "Address" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.patientPaid", "path": "ExplanationOfBenefit.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Item" } ], "path": "ExplanationOfBenefit.item", "short": "Product or service provided", "definition": "A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.", "requirements": "The items to be processed for adjudication.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.id", "path": "ExplanationOfBenefit.item.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.extension", "path": "ExplanationOfBenefit.item.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.modifierExtension", "path": "ExplanationOfBenefit.item.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.sequence", "path": "ExplanationOfBenefit.item.sequence", "short": "Item instance identifier", "definition": "A number to uniquely identify item entries.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.item.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.careTeamSequence", "path": "ExplanationOfBenefit.item.careTeamSequence", "short": "Applicable care team members", "definition": "Care team members related to this service or product.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Need to identify the individuals and their roles in the provision of the product or service.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.careTeamSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.diagnosisSequence", "path": "ExplanationOfBenefit.item.diagnosisSequence", "short": "Applicable diagnoses", "definition": "Diagnoses applicable for this service or product.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Need to related the product or service to the associated diagnoses.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.diagnosisSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.procedureSequence", "path": "ExplanationOfBenefit.item.procedureSequence", "short": "Applicable procedures", "definition": "Procedures applicable for this service or product.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Need to provide any listed specific procedures to support the product or service being claimed.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.procedureSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.informationSequence", "path": "ExplanationOfBenefit.item.informationSequence", "short": "Applicable exception and supporting information", "definition": "Exceptions, special conditions and supporting information applicable for this service or product.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Need to reference the supporting information items that relate directly to this product or service.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.informationSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.traceNumber", "path": "ExplanationOfBenefit.item.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.item.revenue", "path": "ExplanationOfBenefit.item.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.category", "path": "ExplanationOfBenefit.item.category", "short": "Benefit classification", "definition": "Code to identify the general type of benefits under which products and services are provided.", "comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.", "requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.category", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitCategory" } ], "strength": "example", "description": "Benefit categories such as: oral, medical, vision, oral-basic etc.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.productOrService", "path": "ExplanationOfBenefit.item.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.productOrServiceEnd", "path": "ExplanationOfBenefit.item.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.request", "path": "ExplanationOfBenefit.item.request", "short": "Request or Referral for Service", "definition": "Request or Referral for Goods or Service to be rendered.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "May identify the service to be provided or provider authorization for the service.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.request", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "http://hl7.org/fhir/StructureDefinition/ServiceRequest", "http://hl7.org/fhir/StructureDefinition/SupplyRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.item.modifier", "path": "ExplanationOfBenefit.item.modifier", "short": "Product or service billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.programCode", "path": "ExplanationOfBenefit.item.programCode", "short": "Program the product or service is provided under", "definition": "Identifies the program under which this may be recovered.", "comment": "For example: Neonatal program, child dental program or drug users recovery program.", "requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.programCode", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProgramCode" } ], "strength": "example", "description": "Program specific reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.serviced[x]", "path": "ExplanationOfBenefit.item.serviced[x]", "short": "Date or dates of service or product delivery", "definition": "The date or dates when the service or product was supplied, performed or completed.", "requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.serviced[x]", "min": 0, "max": "1" }, "type": [ { "code": "date" }, { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.done[x]" } ] }, { "id": "ExplanationOfBenefit.item.location[x]", "path": "ExplanationOfBenefit.item.location[x]", "short": "Place of service or where product was supplied", "definition": "Where the product or service was provided.", "requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.location[x]", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" }, { "code": "Address" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServicePlace" } ], "strength": "example", "description": "Place where the service is rendered.", "valueSet": "http://hl7.org/fhir/ValueSet/service-place" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.where[x]" } ] }, { "id": "ExplanationOfBenefit.item.patientPaid", "path": "ExplanationOfBenefit.item.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.quantity", "path": "ExplanationOfBenefit.item.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.item.unitPrice", "path": "ExplanationOfBenefit.item.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.factor", "path": "ExplanationOfBenefit.item.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.tax", "path": "ExplanationOfBenefit.item.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.net", "path": "ExplanationOfBenefit.item.net", "short": "Total item cost", "definition": "The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.udi", "path": "ExplanationOfBenefit.item.udi", "short": "Unique device identifier", "definition": "Unique Device Identifiers associated with this line item.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.udi", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.item.bodySite", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "720;600" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "ItemBodySite" } ], "path": "ExplanationOfBenefit.item.bodySite", "short": "Anatomical location", "definition": "Physical location where the service is performed or applies.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.bodySite", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.bodySite.id", "path": "ExplanationOfBenefit.item.bodySite.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.bodySite.extension", "path": "ExplanationOfBenefit.item.bodySite.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.bodySite.modifierExtension", "path": "ExplanationOfBenefit.item.bodySite.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.bodySite.site", "path": "ExplanationOfBenefit.item.bodySite.site", "short": "Location", "definition": "Physical service site on the patient (limb, tooth, etc.).", "comment": "For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.", "requirements": "Allows insurer to validate specific procedures.", "min": 1, "max": "*", "base": { "path": "ExplanationOfBenefit.item.bodySite.site", "min": 1, "max": "*" }, "type": [ { "code": "CodeableReference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/BodyStructure" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "OralSites" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/tooth" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.bodySite.subSite", "path": "ExplanationOfBenefit.item.bodySite.subSite", "short": "Sub-location", "definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Allows insurer to validate specific procedures.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.bodySite.subSite", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Surface" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/surface" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.encounter", "path": "ExplanationOfBenefit.item.encounter", "short": "Encounters associated with the listed treatments", "definition": "Healthcare encounters related to this claim.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Used in some jurisdictions to link clinical events to claim items.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.encounter", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.item.noteNumber", "path": "ExplanationOfBenefit.item.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome", "path": "ExplanationOfBenefit.item.reviewOutcome", "short": "Adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.reviewOutcome", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.id", "path": "ExplanationOfBenefit.item.reviewOutcome.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.extension", "path": "ExplanationOfBenefit.item.reviewOutcome.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension", "path": "ExplanationOfBenefit.item.reviewOutcome.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.decision", "path": "ExplanationOfBenefit.item.reviewOutcome.decision", "short": "Result of the adjudication", "definition": "The result of the claim, predetermination, or preauthorization adjudication.", "comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).", "requirements": "To advise the requestor of the result of the adjudication process.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.reviewOutcome.decision", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjudicationDecision" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/claim-decision" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.reason", "path": "ExplanationOfBenefit.item.reviewOutcome.reason", "short": "Reason for result of the adjudication", "definition": "The reasons for the result of the claim, predetermination, or preauthorization adjudication.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "To advise the requestor of the contributors to the result of the adjudication process.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.reviewOutcome.reason", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjudicationDecisionReason" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/claim-decision-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef", "path": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef", "short": "Preauthorization reference", "definition": "Reference from the Insurer which is used in later communications which refers to this adjudication.", "comment": "This value is only present on preauthorization adjudications.", "requirements": "On subsequent claims, the insurer may require the provider to quote this value.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.reviewOutcome.preAuthRef", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod", "path": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod", "short": "Preauthorization reference effective period", "definition": "The time frame during which this authorization is effective.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "requirements": "To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" } ] }, { "id": "ExplanationOfBenefit.item.adjudication", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Adjudication" } ], "path": "ExplanationOfBenefit.item.adjudication", "short": "Adjudication details", "definition": "If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.", "requirements": "The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.adjudication", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.id", "path": "ExplanationOfBenefit.item.adjudication.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.extension", "path": "ExplanationOfBenefit.item.adjudication.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.modifierExtension", "path": "ExplanationOfBenefit.item.adjudication.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.category", "path": "ExplanationOfBenefit.item.adjudication.category", "short": "Type of adjudication information", "definition": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.", "comment": "For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.", "requirements": "Needed to enable understanding of the context of the other information in the adjudication.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.item.adjudication.category", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Adjudication" } ], "strength": "example", "description": "The adjudication codes.", "valueSet": "http://hl7.org/fhir/ValueSet/adjudication" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.reason", "path": "ExplanationOfBenefit.item.adjudication.reason", "short": "Explanation of adjudication outcome", "definition": "A code supporting the understanding of the adjudication result and explaining variance from expected amount.", "comment": "For example, may indicate that the funds for this benefit type have been exhausted.", "requirements": "To support understanding of variance from adjudication expectations.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.adjudication.reason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "AdjudicationReason" } ], "strength": "example", "description": "Adjudication reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/adjudication-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.amount", "path": "ExplanationOfBenefit.item.adjudication.amount", "short": "Monetary amount", "definition": "Monetary amount associated with the category.", "comment": "For example, amount submitted, eligible amount, co-payment, and benefit payable.", "requirements": "Most adjudication categories convey a monetary amount.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.adjudication.amount", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.adjudication.quantity", "path": "ExplanationOfBenefit.item.adjudication.quantity", "short": "Non-monitary value", "definition": "A non-monetary value associated with the category. Mutually exclusive to the amount element above.", "comment": "For example: eligible percentage or co-payment percentage.", "requirements": "Some adjudication categories convey a percentage or a fixed value.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.adjudication.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.item.detail", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Detail" } ], "path": "ExplanationOfBenefit.item.detail", "short": "Additional items", "definition": "Second-tier of goods and services.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.id", "path": "ExplanationOfBenefit.item.detail.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.extension", "path": "ExplanationOfBenefit.item.detail.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.detail.modifierExtension", "path": "ExplanationOfBenefit.item.detail.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.detail.sequence", "path": "ExplanationOfBenefit.item.detail.sequence", "short": "Product or service provided", "definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "The items to be processed for adjudication.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.traceNumber", "path": "ExplanationOfBenefit.item.detail.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.item.detail.revenue", "path": "ExplanationOfBenefit.item.detail.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.category", "path": "ExplanationOfBenefit.item.detail.category", "short": "Benefit classification", "definition": "Code to identify the general type of benefits under which products and services are provided.", "comment": "Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.", "requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.category", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitCategory" } ], "strength": "example", "description": "Benefit categories such as: oral, medical, vision, oral-basic etc.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.productOrService", "path": "ExplanationOfBenefit.item.detail.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.productOrServiceEnd", "path": "ExplanationOfBenefit.item.detail.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.modifier", "path": "ExplanationOfBenefit.item.detail.modifier", "short": "Service/Product billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.programCode", "path": "ExplanationOfBenefit.item.detail.programCode", "short": "Program the product or service is provided under", "definition": "Identifies the program under which this may be recovered.", "comment": "For example: Neonatal program, child dental program or drug users recovery program.", "requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.programCode", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProgramCode" } ], "strength": "example", "description": "Program specific reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.patientPaid", "path": "ExplanationOfBenefit.item.detail.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.quantity", "path": "ExplanationOfBenefit.item.detail.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.item.detail.unitPrice", "path": "ExplanationOfBenefit.item.detail.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.factor", "path": "ExplanationOfBenefit.item.detail.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.tax", "path": "ExplanationOfBenefit.item.detail.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.net", "path": "ExplanationOfBenefit.item.detail.net", "short": "Total item cost", "definition": "The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.udi", "path": "ExplanationOfBenefit.item.detail.udi", "short": "Unique device identifier", "definition": "Unique Device Identifiers associated with this line item.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.udi", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.item.detail.noteNumber", "path": "ExplanationOfBenefit.item.detail.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.reviewOutcome", "path": "ExplanationOfBenefit.item.detail.reviewOutcome", "short": "Detail level adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.reviewOutcome", "min": 0, "max": "1" }, "contentReference": "#ExplanationOfBenefit.item.reviewOutcome", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.item.detail.adjudication", "path": "ExplanationOfBenefit.item.detail.adjudication", "short": "Detail level adjudication details", "definition": "The adjudication results.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.adjudication", "min": 0, "max": "*" }, "contentReference": "#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.item.detail.subDetail", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "SubDetail" } ], "path": "ExplanationOfBenefit.item.detail.subDetail", "short": "Additional items", "definition": "Third-tier of goods and services.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.id", "path": "ExplanationOfBenefit.item.detail.subDetail.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.extension", "path": "ExplanationOfBenefit.item.detail.subDetail.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension", "path": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.sequence", "path": "ExplanationOfBenefit.item.detail.subDetail.sequence", "short": "Product or service provided", "definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "The items to be processed for adjudication.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.sequence", "min": 1, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.traceNumber", "path": "ExplanationOfBenefit.item.detail.subDetail.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.revenue", "path": "ExplanationOfBenefit.item.detail.subDetail.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.category", "path": "ExplanationOfBenefit.item.detail.subDetail.category", "short": "Benefit classification", "definition": "Code to identify the general type of benefits under which products and services are provided.", "comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.", "requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.category", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitCategory" } ], "strength": "example", "description": "Benefit categories such as: oral, medical, vision, oral-basic etc.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.productOrService", "path": "ExplanationOfBenefit.item.detail.subDetail.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd", "path": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.modifier", "path": "ExplanationOfBenefit.item.detail.subDetail.modifier", "short": "Service/Product billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.programCode", "path": "ExplanationOfBenefit.item.detail.subDetail.programCode", "short": "Program the product or service is provided under", "definition": "Identifies the program under which this may be recovered.", "comment": "For example: Neonatal program, child dental program or drug users recovery program.", "requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.programCode", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProgramCode" } ], "strength": "example", "description": "Program specific reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.patientPaid", "path": "ExplanationOfBenefit.item.detail.subDetail.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.quantity", "path": "ExplanationOfBenefit.item.detail.subDetail.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice", "path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.factor", "path": "ExplanationOfBenefit.item.detail.subDetail.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.tax", "path": "ExplanationOfBenefit.item.detail.subDetail.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.net", "path": "ExplanationOfBenefit.item.detail.subDetail.net", "short": "Total item cost", "definition": "The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.udi", "path": "ExplanationOfBenefit.item.detail.subDetail.udi", "short": "Unique device identifier", "definition": "Unique Device Identifiers associated with this line item.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.udi", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber", "path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.item.detail.subDetail.reviewOutcome", "path": "ExplanationOfBenefit.item.detail.subDetail.reviewOutcome", "short": "Subdetail level adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.reviewOutcome", "min": 0, "max": "1" }, "contentReference": "#ExplanationOfBenefit.item.reviewOutcome", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.item.detail.subDetail.adjudication", "path": "ExplanationOfBenefit.item.detail.subDetail.adjudication", "short": "Subdetail level adjudication details", "definition": "The adjudication results.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.item.detail.subDetail.adjudication", "min": 0, "max": "*" }, "contentReference": "#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "740;600" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "AddedItem" } ], "path": "ExplanationOfBenefit.addItem", "short": "Insurer added line items", "definition": "The first-tier service adjudications for payor added product or service lines.", "requirements": "Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.id", "path": "ExplanationOfBenefit.addItem.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.extension", "path": "ExplanationOfBenefit.addItem.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.modifierExtension", "path": "ExplanationOfBenefit.addItem.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.itemSequence", "path": "ExplanationOfBenefit.addItem.itemSequence", "short": "Item sequence number", "definition": "Claim items which this service line is intended to replace.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides references to the claim items.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.itemSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detailSequence", "path": "ExplanationOfBenefit.addItem.detailSequence", "short": "Detail sequence number", "definition": "The sequence number of the details within the claim item which this line is intended to replace.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides references to the claim details within the claim item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detailSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.subDetailSequence", "path": "ExplanationOfBenefit.addItem.subDetailSequence", "short": "Subdetail sequence number", "definition": "The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides references to the claim sub-details within the claim detail.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.subDetailSequence", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.traceNumber", "path": "ExplanationOfBenefit.addItem.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.addItem.provider", "path": "ExplanationOfBenefit.addItem.provider", "short": "Authorized providers", "definition": "The providers who are authorized for the services rendered to the patient.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.provider", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.source" } ] }, { "id": "ExplanationOfBenefit.addItem.revenue", "path": "ExplanationOfBenefit.addItem.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.productOrService", "path": "ExplanationOfBenefit.addItem.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.productOrServiceEnd", "path": "ExplanationOfBenefit.addItem.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.request", "path": "ExplanationOfBenefit.addItem.request", "short": "Request or Referral for Service", "definition": "Request or Referral for Goods or Service to be rendered.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "May identify the service to be provided or provider authorization for the service.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.request", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "http://hl7.org/fhir/StructureDefinition/ServiceRequest", "http://hl7.org/fhir/StructureDefinition/SupplyRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "source": "http://hl7.org/fhir/StructureDefinition/Reference" }, { "key": "ref-2", "severity": "error", "human": "At least one of reference, identifier and display SHALL be present (unless an extension is provided).", "expression": "reference.exists() or identifier.exists() or display.exists() or extension.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ExplanationOfBenefit.addItem.modifier", "path": "ExplanationOfBenefit.addItem.modifier", "short": "Service/Product billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.programCode", "path": "ExplanationOfBenefit.addItem.programCode", "short": "Program the product or service is provided under", "definition": "Identifies the program under which this may be recovered.", "comment": "For example: Neonatal program, child dental program or drug users recovery program.", "requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.programCode", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProgramCode" } ], "strength": "example", "description": "Program specific reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.serviced[x]", "path": "ExplanationOfBenefit.addItem.serviced[x]", "short": "Date or dates of service or product delivery", "definition": "The date or dates when the service or product was supplied, performed or completed.", "requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.serviced[x]", "min": 0, "max": "1" }, "type": [ { "code": "date" }, { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.done[x]" } ] }, { "id": "ExplanationOfBenefit.addItem.location[x]", "path": "ExplanationOfBenefit.addItem.location[x]", "short": "Place of service or where product was supplied", "definition": "Where the product or service was provided.", "requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.location[x]", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" }, { "code": "Address" }, { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServicePlace" } ], "strength": "example", "description": "Place where the service is rendered.", "valueSet": "http://hl7.org/fhir/ValueSet/service-place" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.where[x]" } ] }, { "id": "ExplanationOfBenefit.addItem.patientPaid", "path": "ExplanationOfBenefit.addItem.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.quantity", "path": "ExplanationOfBenefit.addItem.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.addItem.unitPrice", "path": "ExplanationOfBenefit.addItem.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.factor", "path": "ExplanationOfBenefit.addItem.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.tax", "path": "ExplanationOfBenefit.addItem.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.net", "path": "ExplanationOfBenefit.addItem.net", "short": "Total item cost", "definition": "The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "780;600" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "AddedItemBodySite" } ], "path": "ExplanationOfBenefit.addItem.bodySite", "short": "Anatomical location", "definition": "Physical location where the service is performed or applies.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.bodySite", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite.id", "path": "ExplanationOfBenefit.addItem.bodySite.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite.extension", "path": "ExplanationOfBenefit.addItem.bodySite.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite.modifierExtension", "path": "ExplanationOfBenefit.addItem.bodySite.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite.site", "path": "ExplanationOfBenefit.addItem.bodySite.site", "short": "Location", "definition": "Physical service site on the patient (limb, tooth, etc.).", "comment": "For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.", "requirements": "Allows insurer to validate specific procedures.", "min": 1, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.bodySite.site", "min": 1, "max": "*" }, "type": [ { "code": "CodeableReference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/BodyStructure" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "OralSites" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/tooth" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.bodySite.subSite", "path": "ExplanationOfBenefit.addItem.bodySite.subSite", "short": "Sub-location", "definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Allows insurer to validate specific procedures.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.bodySite.subSite", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Surface" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/surface" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.noteNumber", "path": "ExplanationOfBenefit.addItem.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.reviewOutcome", "path": "ExplanationOfBenefit.addItem.reviewOutcome", "short": "Additem level adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.reviewOutcome", "min": 0, "max": "1" }, "contentReference": "#ExplanationOfBenefit.item.reviewOutcome", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem.adjudication", "path": "ExplanationOfBenefit.addItem.adjudication", "short": "Added items adjudication", "definition": "The adjudication results.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.adjudication", "min": 0, "max": "*" }, "contentReference": "#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem.detail", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "740;600" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "AddedItemDetail" } ], "path": "ExplanationOfBenefit.addItem.detail", "short": "Insurer added line items", "definition": "The second-tier service adjudications for payor added services.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.id", "path": "ExplanationOfBenefit.addItem.detail.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.extension", "path": "ExplanationOfBenefit.addItem.detail.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.modifierExtension", "path": "ExplanationOfBenefit.addItem.detail.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.traceNumber", "path": "ExplanationOfBenefit.addItem.detail.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.revenue", "path": "ExplanationOfBenefit.addItem.detail.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.productOrService", "path": "ExplanationOfBenefit.addItem.detail.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd", "path": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.modifier", "path": "ExplanationOfBenefit.addItem.detail.modifier", "short": "Service/Product billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.patientPaid", "path": "ExplanationOfBenefit.addItem.detail.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.quantity", "path": "ExplanationOfBenefit.addItem.detail.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.unitPrice", "path": "ExplanationOfBenefit.addItem.detail.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.factor", "path": "ExplanationOfBenefit.addItem.detail.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.tax", "path": "ExplanationOfBenefit.addItem.detail.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.net", "path": "ExplanationOfBenefit.addItem.detail.net", "short": "Total item cost", "definition": "The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.noteNumber", "path": "ExplanationOfBenefit.addItem.detail.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.reviewOutcome", "path": "ExplanationOfBenefit.addItem.detail.reviewOutcome", "short": "Additem detail level adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.reviewOutcome", "min": 0, "max": "1" }, "contentReference": "#ExplanationOfBenefit.item.reviewOutcome", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem.detail.adjudication", "path": "ExplanationOfBenefit.addItem.detail.adjudication", "short": "Added items adjudication", "definition": "The adjudication results.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.adjudication", "min": 0, "max": "*" }, "contentReference": "#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "740;600" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "AddedItemDetailSubDetail" } ], "path": "ExplanationOfBenefit.addItem.detail.subDetail", "short": "Insurer added line items", "definition": "The third-tier service adjudications for payor added services.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.id", "path": "ExplanationOfBenefit.addItem.detail.subDetail.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.extension", "path": "ExplanationOfBenefit.addItem.detail.subDetail.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension", "path": "ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber", "path": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber", "short": "Number for tracking", "definition": "Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.", "comment": "The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.", "requirements": "Allows partners to uniquely identify components for tracking.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.traceNumber", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.revenue", "path": "ExplanationOfBenefit.addItem.detail.subDetail.revenue", "short": "Revenue or cost center code", "definition": "The type of revenue or cost center providing the product and/or service.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed in the processing of institutional claims.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.revenue", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "RevenueCenter" } ], "strength": "example", "description": "Codes for the revenue or cost centers supplying the service and/or products.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService", "path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService", "short": "Billing, service, product, or drug code", "definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.", "comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.", "requirements": "Necessary to state what was provided or done.", "alias": [ "Drug Code", "Bill Code", "Service Code" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrService", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "description": "Allowable service and product codes.", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd", "path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd", "short": "End of a range of codes", "definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ], "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ServiceProduct" } ], "strength": "example", "valueSet": "http://hl7.org/fhir/ValueSet/service-uscls" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.modifier", "path": "ExplanationOfBenefit.addItem.detail.subDetail.modifier", "short": "Service/Product billing modifiers", "definition": "Item typification or modifiers codes to convey additional context for the product or service.", "comment": "For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.", "requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.modifier", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Modifiers" } ], "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.", "valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid", "path": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid", "short": "Paid by the patient", "definition": "The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.", "requirements": "Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.patientPaid", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.quantity", "path": "ExplanationOfBenefit.addItem.detail.subDetail.quantity", "short": "Count of products or services", "definition": "The number of repetitions of a service or product.", "comment": "The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.", "requirements": "Required when the product or service code does not convey the quantity provided.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.quantity", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice", "path": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice", "short": "Fee, charge or cost per item", "definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.", "requirements": "The amount charged to the patient by the provider for a single unit.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.unitPrice", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.factor", "path": "ExplanationOfBenefit.addItem.detail.subDetail.factor", "short": "Price scaling factor", "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.", "comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).", "requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.factor", "min": 0, "max": "1" }, "type": [ { "code": "decimal" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.tax", "path": "ExplanationOfBenefit.addItem.detail.subDetail.tax", "short": "Total tax", "definition": "The total of taxes applicable for this product or service.", "requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.tax", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.net", "path": "ExplanationOfBenefit.addItem.detail.subDetail.net", "short": "Total item cost", "definition": "The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor.", "comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.", "requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.net", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber", "path": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber", "short": "Applicable note numbers", "definition": "The numbers associated with notes below which apply to the adjudication of this item.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.noteNumber", "min": 0, "max": "*" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome", "path": "ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome", "short": "Additem subdetail level adjudication results", "definition": "The high-level results of the adjudication if adjudication has been performed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome", "min": 0, "max": "1" }, "contentReference": "#ExplanationOfBenefit.item.reviewOutcome", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication", "path": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication", "short": "Added items adjudication", "definition": "The adjudication results.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.addItem.detail.subDetail.adjudication", "min": 0, "max": "*" }, "contentReference": "#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.adjudication", "path": "ExplanationOfBenefit.adjudication", "short": "Header-level adjudication", "definition": "The adjudication results which are presented at the header level rather than at the line-item or add-item levels.", "requirements": "Some insurers will receive line-items but provide the adjudication only at a summary or header-level.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.adjudication", "min": 0, "max": "*" }, "contentReference": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication", "mustSupport": false, "isModifier": false, "isSummary": false }, { "id": "ExplanationOfBenefit.total", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "'360;620" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Total" } ], "path": "ExplanationOfBenefit.total", "slicing": { "discriminator": [ { "type": "value", "path": "category" } ], "rules": "open" }, "short": "Adjudication totals", "definition": "Categorized monetary totals for the adjudication.", "comment": "Totals for amounts submitted, co-pays, benefits payable etc.", "requirements": "To provide the requestor with financial totals by category for the adjudication.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.total", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.total.id", "path": "ExplanationOfBenefit.total.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.total.extension", "path": "ExplanationOfBenefit.total.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.total.modifierExtension", "path": "ExplanationOfBenefit.total.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.total.category", "path": "ExplanationOfBenefit.total.category", "short": "Type of adjudication information", "definition": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.", "comment": "For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.", "requirements": "Needed to convey the type of total provided.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.total.category", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Adjudication" } ], "strength": "example", "description": "The adjudication codes.", "valueSet": "http://hl7.org/fhir/ValueSet/adjudication" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.total.amount", "path": "ExplanationOfBenefit.total.amount", "short": "Financial total for the category", "definition": "Monetary total amount associated with the category.", "requirements": "Needed to convey the total monetary amount.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.total.amount", "min": 1, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.total:eligible", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "'360;620" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Total" } ], "path": "ExplanationOfBenefit.total", "sliceName": "eligible", "short": "Total eligible expenses submitted", "definition": "This is the total eligible amounts from submitted drug expenses for the specified coverage year", "comment": "Totals for amounts submitted, co-pays, benefits payable etc.", "requirements": "To provide the requestor with financial totals by category for the adjudication.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.total", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.total:eligible.id", "path": "ExplanationOfBenefit.total.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.total:eligible.extension", "path": "ExplanationOfBenefit.total.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.total:eligible.modifierExtension", "path": "ExplanationOfBenefit.total.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.total:eligible.category", "path": "ExplanationOfBenefit.total.category", "short": "Type of adjudication information", "definition": "A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.", "comment": "For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.", "requirements": "Needed to convey the type of total provided.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.total.category", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Adjudication" } ], "strength": "required", "description": "The adjudication codes.", "valueSet": "https://bpcs.exchange/fhir/ValueSet/vs-EOBIndividualCategories" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.total:eligible.amount", "path": "ExplanationOfBenefit.total.amount", "short": "Financial total for the category", "definition": "Monetary total amount associated with the category.", "requirements": "Needed to convey the total monetary amount.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.total.amount", "min": 1, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" }, { "identity": "BPCS", "map": "RecipientExpensesDTO.accumulatedAllowedExpenseCurrent or accumulatedAllowedExpensePrevious (depending on benefit year)" } ] }, { "id": "ExplanationOfBenefit.payment", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "360;650" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Payment" } ], "path": "ExplanationOfBenefit.payment", "short": "Payment Details", "definition": "Payment details for the adjudication of the claim.", "requirements": "Needed to convey references to the financial instrument that has been used if payment has been made.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payment.id", "path": "ExplanationOfBenefit.payment.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payment.extension", "path": "ExplanationOfBenefit.payment.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.payment.modifierExtension", "path": "ExplanationOfBenefit.payment.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.payment.type", "path": "ExplanationOfBenefit.payment.type", "short": "Partial or complete payment", "definition": "Whether this represents partial or complete payment of the benefits payable.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "To advise the requestor when the insurer believes all payments to have been completed.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "PaymentType" } ], "strength": "example", "description": "The type (partial, complete) of the payment.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-paymenttype" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.payment.adjustment", "path": "ExplanationOfBenefit.payment.adjustment", "short": "Payment adjustment for non-claim issues", "definition": "Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.", "comment": "Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.", "requirements": "To advise the requestor of adjustments applied to the payment.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.adjustment", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.payment.adjustmentReason", "path": "ExplanationOfBenefit.payment.adjustmentReason", "short": "Explanation for the variance", "definition": "Reason for the payment adjustment.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed to clarify the monetary adjustment.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.adjustmentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "PaymentAdjustmentReason" } ], "strength": "example", "description": "Payment Adjustment reason codes.", "valueSet": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.payment.date", "path": "ExplanationOfBenefit.payment.date", "short": "Expected date of payment", "definition": "Estimated date the payment will be issued or the actual issue date of payment.", "requirements": "To advise the payee when payment can be expected.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.date", "min": 0, "max": "1" }, "type": [ { "code": "date" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.payment.amount", "path": "ExplanationOfBenefit.payment.amount", "short": "Payable amount after adjustment", "definition": "Benefits payable less any payment adjustment.", "requirements": "Needed to provide the actual payment amount.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.amount", "min": 0, "max": "1" }, "type": [ { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "MO" } ] }, { "id": "ExplanationOfBenefit.payment.identifier", "path": "ExplanationOfBenefit.payment.identifier", "short": "Business identifier for the payment", "definition": "Issuer's unique identifier for the payment instrument.", "comment": "For example: EFT number or check number.", "requirements": "Enable the receiver to reconcile when payment received.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.payment.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ident-1", "severity": "warning", "human": "Identifier with no value has limited utility. If communicating that an identifier value has been suppressed or missing, the value element SHOULD be present with an extension indicating the missing semantic - e.g. data-absent-reason", "expression": "value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Identifier" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" } ] }, { "id": "ExplanationOfBenefit.formCode", "path": "ExplanationOfBenefit.formCode", "short": "Printed form identifier", "definition": "A code for the form to be used for printing the content.", "comment": "May be needed to identify specific jurisdictional forms.", "requirements": "Needed to specify the specific form used for producing output for this response.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.formCode", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Forms" } ], "strength": "example", "description": "The forms codes.", "valueSet": "http://hl7.org/fhir/ValueSet/forms" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.form", "path": "ExplanationOfBenefit.form", "short": "Printed reference or actual form", "definition": "The actual form, by reference or inclusion, for printing the content or an EOB.", "comment": "Needed to permit insurers to include the actual form.", "requirements": "Needed to include the specific form used for producing output for this response.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.form", "min": 0, "max": "1" }, "type": [ { "code": "Attachment" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "att-1", "severity": "error", "human": "If the Attachment has data, it SHALL have a contentType", "expression": "data.empty() or contentType.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Attachment" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ED/RP" }, { "identity": "rim", "map": "ED" } ] }, { "id": "ExplanationOfBenefit.processNote", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Note" } ], "path": "ExplanationOfBenefit.processNote", "short": "Note concerning adjudication", "definition": "A note that describes or explains adjudication results in a human readable form.", "requirements": "Provides the insurer specific textual explanations associated with the processing.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.processNote", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.processNote.id", "path": "ExplanationOfBenefit.processNote.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.processNote.extension", "path": "ExplanationOfBenefit.processNote.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.processNote.modifierExtension", "path": "ExplanationOfBenefit.processNote.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.processNote.number", "path": "ExplanationOfBenefit.processNote.number", "short": "Note instance identifier", "definition": "A number to uniquely identify a note entry.", "comment": "32 bit number; for values larger than this, use decimal", "requirements": "Necessary to provide a mechanism to link from adjudications.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.processNote.number", "min": 0, "max": "1" }, "type": [ { "code": "positiveInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.processNote.type", "path": "ExplanationOfBenefit.processNote.type", "short": "Note purpose", "definition": "The business purpose of the note text.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "To convey the expectation for when the text is used.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.processNote.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "NoteType" } ], "strength": "extensible", "description": "The presentation types of notes.", "valueSet": "http://hl7.org/fhir/ValueSet/note-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.processNote.text", "path": "ExplanationOfBenefit.processNote.text", "short": "Note explanatory text", "definition": "The explanation or description associated with the processing.", "comment": "Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size", "requirements": "Required to provide human readable explanation.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.processNote.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.processNote.language", "path": "ExplanationOfBenefit.processNote.language", "short": "Language of the text", "definition": "A code to define the language used in the text of the note.", "comment": "Only required if the language is different from the resource language.", "requirements": "Note text may vary from the resource defined language.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.processNote.language", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "required", "description": "IETF language tag for a human language", "valueSet": "http://hl7.org/fhir/ValueSet/all-languages|5.0.0", "additional": [ { "purpose": "starter", "valueSet": "http://hl7.org/fhir/ValueSet/languages" } ] }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod", "path": "ExplanationOfBenefit.benefitPeriod", "short": "When the benefits are applicable", "definition": "The term of the benefits documented in this response.", "comment": "Not applicable when use=claim.", "requirements": "Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitPeriod", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower or equal value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start.lowBoundary() <= end.highBoundary())", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod.id", "path": "ExplanationOfBenefit.benefitPeriod.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod.extension", "path": "ExplanationOfBenefit.benefitPeriod.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod.start", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/minLength", "valueInteger": 10 } ], "path": "ExplanationOfBenefit.benefitPeriod.start", "short": "Primitive Type dateTime", "definition": "This is the start of the quarter (Aug. 1, Nov. 1, Feb 1, or May 1) for which the totals are being reported", "comment": "UTC offset is allowed for dates and partial dates", "min": 1, "max": "1", "base": { "path": "Period.start", "min": 0, "max": "1" }, "type": [ { "code": "dateTime", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-dateTime-date" ] } ], "maxLength": 10, "condition": [ "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.1" }, { "identity": "rim", "map": "./low" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod.end", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/minLength", "valueInteger": 10 } ], "path": "ExplanationOfBenefit.benefitPeriod.end", "short": "Primitive Type dateTime", "definition": "This is the end of the quarter (Oct 31, Jan 31, Apr 30, or Jul 31) for which the totals are being reported", "comment": "UTC offset is allowed for dates and partial dates", "min": 1, "max": "1", "base": { "path": "Period.end", "min": 0, "max": "1" }, "type": [ { "code": "dateTime", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-dateTime-date" ] } ], "meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing", "maxLength": 10, "condition": [ "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.2" }, { "identity": "rim", "map": "./high" } ] }, { "id": "ExplanationOfBenefit.benefitBalance", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "BenefitBalance" } ], "path": "ExplanationOfBenefit.benefitBalance", "short": "Balance by Benefit Category", "definition": "Balance by Benefit Category.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.benefitBalance", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.id", "path": "ExplanationOfBenefit.benefitBalance.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.extension", "path": "ExplanationOfBenefit.benefitBalance.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.modifierExtension", "path": "ExplanationOfBenefit.benefitBalance.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.category", "path": "ExplanationOfBenefit.benefitBalance.category", "short": "Benefit classification", "definition": "Code to identify the general type of benefits under which products and services are provided.", "comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.", "requirements": "Needed to convey the category of service or product for which eligibility is sought.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.category", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitCategory" } ], "strength": "example", "description": "Benefit categories such as: oral, medical, vision, oral-basic etc.", "valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.excluded", "path": "ExplanationOfBenefit.benefitBalance.excluded", "short": "Excluded from the plan", "definition": "True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.", "requirements": "Needed to identify items that are specifically excluded from the coverage.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.excluded", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.name", "path": "ExplanationOfBenefit.benefitBalance.name", "short": "Short name for the benefit", "definition": "A short name or tag for the benefit.", "comment": "For example: MED01, or DENT2.", "requirements": "Required to align with other plan names.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.name", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.description", "path": "ExplanationOfBenefit.benefitBalance.description", "short": "Description of the benefit or services covered", "definition": "A richer description of the benefit or services covered.", "comment": "For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.", "requirements": "Needed for human readable reference.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.description", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.network", "path": "ExplanationOfBenefit.benefitBalance.network", "short": "In or out of network", "definition": "Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed as in or out of network providers are treated differently under the coverage.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.network", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitNetwork" } ], "strength": "example", "description": "Code to classify in or out of network services.", "valueSet": "http://hl7.org/fhir/ValueSet/benefit-network" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.unit", "path": "ExplanationOfBenefit.benefitBalance.unit", "short": "Individual or family", "definition": "Indicates if the benefits apply to an individual or to the family.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed for the understanding of the benefits.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.unit", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitUnit" } ], "strength": "example", "description": "Unit covered/serviced - individual or family.", "valueSet": "http://hl7.org/fhir/ValueSet/benefit-unit" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.term", "path": "ExplanationOfBenefit.benefitBalance.term", "short": "Annual or lifetime", "definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "requirements": "Needed for the understanding of the benefits.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.term", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitTerm" } ], "strength": "example", "description": "Coverage unit - annual, lifetime.", "valueSet": "http://hl7.org/fhir/ValueSet/benefit-term" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Benefit" } ], "path": "ExplanationOfBenefit.benefitBalance.financial", "short": "Benefit Summary", "definition": "Benefits Used to date.", "min": 0, "max": "*", "base": { "path": "ExplanationOfBenefit.benefitBalance.financial", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.id", "path": "ExplanationOfBenefit.benefitBalance.financial.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "condition": [ "ele-1" ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.extension", "path": "ExplanationOfBenefit.benefitBalance.financial.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension", "path": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.type", "path": "ExplanationOfBenefit.benefitBalance.financial.type", "short": "Benefit classification", "definition": "Classification of benefit being provided.", "comment": "For example: deductible, visits, benefit amount.", "requirements": "Needed to convey the nature of the benefit.", "min": 1, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.financial.type", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BenefitType" } ], "strength": "example", "description": "Deductable, visits, co-pay, etc.", "valueSet": "http://hl7.org/fhir/ValueSet/benefit-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]", "path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]", "short": "Benefits allowed", "definition": "The quantity of the benefit which is permitted under the coverage.", "requirements": "Needed to convey the benefits offered under the coverage.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]", "min": 0, "max": "1" }, "type": [ { "code": "unsignedInt" }, { "code": "string" }, { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ExplanationOfBenefit.benefitBalance.financial.used[x]", "path": "ExplanationOfBenefit.benefitBalance.financial.used[x]", "short": "Benefits used", "definition": "The quantity of the benefit which have been consumed to date.", "requirements": "Needed to convey the benefits consumed to date.", "min": 0, "max": "1", "base": { "path": "ExplanationOfBenefit.benefitBalance.financial.used[x]", "min": 0, "max": "1" }, "type": [ { "code": "unsignedInt" }, { "code": "Money" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] } ] }, "differential": { "element": [ { "id": "ExplanationOfBenefit.id", "path": "ExplanationOfBenefit.id", "comment": "This id will always be a random UUID, which will change each time a query is done - because the calculation is performed anew each time", "min": 1, "mustSupport": true }, { "id": "ExplanationOfBenefit.status", "path": "ExplanationOfBenefit.status", "patternCode": "active" }, { "id": "ExplanationOfBenefit.type", "path": "ExplanationOfBenefit.type", "patternCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] } }, { "id": "ExplanationOfBenefit.use", "path": "ExplanationOfBenefit.use", "patternCode": "claim" }, { "id": "ExplanationOfBenefit.patient", "path": "ExplanationOfBenefit.patient", "type": [ { "code": "Reference", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-Reference-rest" ], "targetProfile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-Patient-search" ] } ], "mustSupport": true, "mapping": [ { "identity": "BPCS", "map": "RecipientExpensesDTO.odbNum" } ] }, { "id": "ExplanationOfBenefit.created", "path": "ExplanationOfBenefit.created", "comment": "This will be the date/time the operation was executed", "mustSupport": true }, { "id": "ExplanationOfBenefit.insurer", "path": "ExplanationOfBenefit.insurer", "patternReference": { "reference": "Organization/bpcs" } }, { "id": "ExplanationOfBenefit.outcome", "path": "ExplanationOfBenefit.outcome", "patternCode": "complete" }, { "id": "ExplanationOfBenefit.total", "path": "ExplanationOfBenefit.total", "slicing": { "discriminator": [ { "type": "value", "path": "category" } ], "rules": "open" } }, { "id": "ExplanationOfBenefit.total:eligible", "path": "ExplanationOfBenefit.total", "sliceName": "eligible", "short": "Total eligible expenses submitted", "definition": "This is the total eligible amounts from submitted drug expenses for the specified coverage year", "mustSupport": true }, { "id": "ExplanationOfBenefit.total:eligible.category", "path": "ExplanationOfBenefit.total.category", "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://bpcs.exchange/fhir/ValueSet/vs-EOBIndividualCategories" } }, { "id": "ExplanationOfBenefit.total:eligible.amount", "path": "ExplanationOfBenefit.total.amount", "mustSupport": true, "mapping": [ { "identity": "BPCS", "map": "RecipientExpensesDTO.accumulatedAllowedExpenseCurrent or accumulatedAllowedExpensePrevious (depending on benefit year)" } ] }, { "id": "ExplanationOfBenefit.benefitPeriod", "path": "ExplanationOfBenefit.benefitPeriod", "min": 1, "mustSupport": true }, { "id": "ExplanationOfBenefit.benefitPeriod.start", "path": "ExplanationOfBenefit.benefitPeriod.start", "definition": "This is the start of the quarter (Aug. 1, Nov. 1, Feb 1, or May 1) for which the totals are being reported", "min": 1, "type": [ { "code": "dateTime", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-dateTime-date" ] } ], "mustSupport": true }, { "id": "ExplanationOfBenefit.benefitPeriod.end", "path": "ExplanationOfBenefit.benefitPeriod.end", "definition": "This is the end of the quarter (Oct 31, Jan 31, Apr 30, or Jul 31) for which the totals are being reported", "min": 1, "type": [ { "code": "dateTime", "profile": [ "https://bpcs.exchange/fhir/StructureDefinition/profile-dateTime-date" ] } ], "mustSupport": true } ] } }