<status value="active" /> <experimental value="false" /> <date value="2023-11-02" /> <publisher value="b.Well Connected Health" /> <description value="Explanation of benefit resource for medical claims data. Aims to adhere to the CARIN IG: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit" /> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166" /> <code value="US" /> <display value="United States of America" /> </coding> <text value="United States of America" /> </jurisdiction> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="ExplanationOfBenefit" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit" /> <derivation value="constraint" /> <differential> <element id="ExplanationOfBenefit.meta"> <path value="ExplanationOfBenefit.meta" /> <type> <code value="Meta" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-meta" /> </type> </element> <element id="ExplanationOfBenefit.meta.security"> <path value="ExplanationOfBenefit.meta.security" /> <slicing> <description value="slice by system and code" /> <rules value="open" /> </slicing> <min value="2" /> </element> <element id="ExplanationOfBenefit.identifier"> <path value="ExplanationOfBenefit.identifier" /> <label value="identifier" /> <slicing> <description value="slice by types" /> <rules value="open" /> </slicing> <short value="a value to identify the resource by" /> <min value="1" /> <type> <code value="Identifier" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-identifier" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.identifier:claim-number"> <path value="ExplanationOfBenefit.identifier" /> <sliceName value="claim-number" /> <short value="An identifier to the insurance claim / EOB" /> <min value="1" /> <max value="1" /> <patternIdentifier> <type> <coding> <system value="https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type" /> <code value="Claim_Nbr" /> </coding> <coding> <system value="https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type" /> <code value="claimnumber" /> </coding> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" /> <code value="uc" /> <display value="Unique claim ID" /> </coding> <text value="Claim Number" /> </type> </patternIdentifier> <example> <label value="Example EOB.identifier: claim-number" /> <valueIdentifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203" /> <code value="Claim_Nbr" /> <display value="Claim Number" /> </coding> <text value="Claim Number" /> </type> <system value="https://www.some-health.org" /> <value value="A123456789" /> </valueIdentifier> </example> </element> <element id="ExplanationOfBenefit.status"> <path value="ExplanationOfBenefit.status" /> <short value="Claim status" /> <comment value="default to active" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.type"> <path value="ExplanationOfBenefit.type" /> <short value="Medical claim type" /> <definition value="institutional or professional" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type" /> </coding> </patternCodeableConcept> <example> <label value="Example EOB.type: institutional" /> <valueCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type" /> <code value="institutional" /> <display value="Institutional" /> </coding> <text value="Institutional" /> </valueCodeableConcept> </example> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.subType"> <path value="ExplanationOfBenefit.subType" /> <short value="More granular claim type (inpatient or outpatient)" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <example> <label value="Example EOB.subType: outpatient" /> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType" /> <code value="outpatient" /> <display value="Outpatient" /> </coding> <text value="Outpatient" /> </valueCodeableConcept> </example> <mustSupport value="true" /> <binding> <strength value="preferred" /> <valueSet value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType" /> </binding> </element> <element id="ExplanationOfBenefit.use"> <path value="ExplanationOfBenefit.use" /> <short value="Fixed: 'claim'" /> <fixedCode value="claim" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.patient"> <path value="ExplanationOfBenefit.patient" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-patient" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.billablePeriod"> <path value="ExplanationOfBenefit.billablePeriod" /> <comment value="Sometimes only provided as dates of service" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.created"> <path value="ExplanationOfBenefit.created" /> <short value="When the claim record was created" /> <comment value="Will be set to the ending date of service if not otherwise specified" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurer"> <path value="ExplanationOfBenefit.insurer" /> <short value="Insurance company covering benefits" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-insurance-company" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.provider"> <path value="ExplanationOfBenefit.provider" /> <label value="billing-provider" /> <short value="Billing provider" /> <comment value="This is typically an Organization, but can sometimes be a Practitioner. NPIs should be verified as either type 1 (Practitioner) or type 2 (Organization)." /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> </type> <example> <label value="Example EOB.provider billing organization" /> <valueReference> <reference value="Organization/1234567890|nppes" /> <display value="1234567890" /> </valueReference> </example> <example> <label value="Example EOB.provider missing billing provider" /> <valueReference> <reference value="Organization/NI" /> <display value="NoInformation" /> </valueReference> </example> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.outcome"> <path value="ExplanationOfBenefit.outcome" /> <short value="complete | partial" /> <comment value="If not provided, presumed complete" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam"> <path value="ExplanationOfBenefit.careTeam" /> <label value="care-team" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <short value="Providers listed on the claim" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.id"> <path value="ExplanationOfBenefit.careTeam.id" /> <comment value="Set as role code to ensure only one entry of said type is included in the array" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="preferred" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-claim-care-team-role" /> </binding> </element> <element id="ExplanationOfBenefit.careTeam:billing-provider"> <path value="ExplanationOfBenefit.careTeam" /> <sliceName value="billing-provider" /> <short value="The billing provider" /> <definition value="The Organization or Practitioner that billed for the products and services." /> <max value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:billing-provider.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <short value="Fixed: 1" /> <fixedPositiveInt value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:billing-provider.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <comment value="This is typically an Organization, but can sometimes be a Practitioner. NPIs should be verified as either type 1 (Practitioner) or type 2 (Organization)." /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> </type> </element> <element id="ExplanationOfBenefit.careTeam:billing-provider.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <short value="Fixed: True" /> <fixedBoolean value="true" /> </element> <element id="ExplanationOfBenefit.careTeam:billing-provider.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <patternCodeableConcept> <coding> <code value="billing" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.careTeam:servicing-provider"> <path value="ExplanationOfBenefit.careTeam" /> <sliceName value="servicing-provider" /> <short value="The provider rendering care" /> <alias value="rendering-provider" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:servicing-provider.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <short value="Fixed: 2" /> <fixedPositiveInt value="2" /> </element> <element id="ExplanationOfBenefit.careTeam:servicing-provider.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <short value="Fixed: False" /> <fixedBoolean value="true" /> </element> <element id="ExplanationOfBenefit.careTeam:servicing-provider.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" /> <code value="rendering" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.careTeam:attending-provider"> <path value="ExplanationOfBenefit.careTeam" /> <sliceName value="attending-provider" /> <short value="The attending practitioner" /> <definition value="The members of the team who provided the products and services. Typically only found on inpatient claims." /> <max value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:attending-provider.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <short value="Fixed: 3" /> <fixedPositiveInt value="3" /> </element> <element id="ExplanationOfBenefit.careTeam:attending-provider.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <short value="Practitioner" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> </type> </element> <element id="ExplanationOfBenefit.careTeam:attending-provider.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <short value="Fixed: False" /> <fixedBoolean value="true" /> </element> <element id="ExplanationOfBenefit.careTeam:attending-provider.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <patternCodeableConcept> <coding> <code value="attending" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo"> <path value="ExplanationOfBenefit.supportingInfo" /> <label value="supporting-info" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <comment value="Set to category code to ensure only one entry for said type." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="preferred" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-claim-information-category" /> </binding> </element> <element id="ExplanationOfBenefit.supportingInfo.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo:claim-received-date"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="claim-received-date" /> <short value="Date the claim was received" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:claim-received-date.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:claim-received-date.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="clmrecvddate" /> <display value="Claim Received Date" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:claim-received-date.timing[x]"> <path value="ExplanationOfBenefit.supportingInfo.timing[x]" /> <short value="The date the claim was received" /> <min value="1" /> <type> <code value="date" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:type-of-bill"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="type-of-bill" /> <short value="The NUBC bill type code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:type-of-bill.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="2" /> </element> <element id="ExplanationOfBenefit.supportingInfo:type-of-bill.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="typeofbill" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:type-of-bill.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="The NUBC bill type code" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="https://www.nubc.org/CodeSystem/TypeOfBill" /> </coding> </patternCodeableConcept> <binding> <strength value="required" /> <description value="NUBC Type of Bill" /> <valueSet value="https://www.nubc.org/CodeSystem/TypeOfBill" /> </binding> </element> <element id="ExplanationOfBenefit.supportingInfo:point-of-origin"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="point-of-origin" /> <short value="The NUBC point of origin code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:point-of-origin.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="3" /> </element> <element id="ExplanationOfBenefit.supportingInfo:point-of-origin.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="pointoforigin" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:point-of-origin.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="The NUBC point of origin code value" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://www.nubc.org/CodeSystem/PointOfOrigin" /> </coding> </patternCodeableConcept> <binding> <strength value="required" /> <description value="NUBC Point of Origin" /> <valueSet value="https://www.nubc.org/CodeSystem/PointOfOrigin" /> </binding> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-type"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="admit-type" /> <short value="The NUBC admission type code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-type.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="4" /> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-type.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="admtype" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-type.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="The NUBC admit type code value" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit" /> </coding> </patternCodeableConcept> <binding> <strength value="required" /> <description value="NUBC Priority Type of Admit or Visit" /> <valueSet value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit" /> </binding> </element> <element id="ExplanationOfBenefit.supportingInfo:discharge-status"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="discharge-status" /> <short value="The NUBC discharge status code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:discharge-status.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="5" /> </element> <element id="ExplanationOfBenefit.supportingInfo:discharge-status.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="discharge-status" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:discharge-status.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="The NUBC discharge status code value" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://www.nubc.org/CodeSystem/PatDischargeStatus" /> </coding> </patternCodeableConcept> <binding> <strength value="required" /> <description value="NUBC Discharge Status" /> <valueSet value="https://www.nubc.org/CodeSystem/PatDischargeStatus" /> </binding> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-period"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="admit-period" /> <short value="The inpatient admission period" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-period.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="6" /> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-period.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="admissionperiod" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:admit-period.timing[x]"> <path value="ExplanationOfBenefit.supportingInfo.timing[x]" /> <short value="Admission period start and end dates" /> <min value="1" /> <type> <code value="Period" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:drg"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="drg" /> <short value="The DRG code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:drg.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="7" /> </element> <element id="ExplanationOfBenefit.supportingInfo:drg.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="drg" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:drg.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="The DRG code value" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:place-of-service"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="place-of-service" /> <short value="Place of service code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:place-of-service.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:place-of-service.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <fixedPositiveInt value="8" /> </element> <element id="ExplanationOfBenefit.supportingInfo:place-of-service.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory" /> <code value="placeofservice" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:place-of-service.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-setsl" /> </coding> </patternCodeableConcept> <example> <label value="Example EOB.supportingInfo place of service" /> <valueCodeableConcept> <coding> <system value="https://www.cms.gov/medicare/coding-billing/place-of-service-code" /> <code value="11" /> <display value="Office" /> </coding> </valueCodeableConcept> </example> </element> <element id="ExplanationOfBenefit.diagnosis"> <path value="ExplanationOfBenefit.diagnosis" /> <alias value="icd-diagnosis" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.id"> <path value="ExplanationOfBenefit.diagnosis.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.sequence"> <path value="ExplanationOfBenefit.diagnosis.sequence" /> <label value="diagnosis" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.diagnosis[x]"> <path value="ExplanationOfBenefit.diagnosis.diagnosis[x]" /> <short value="ICD diagnosis code" /> <comment value="Decimal points are preferred." /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <example> <label value="Example EOB.diagnosis.diagnosisCodeableConcept ICD-10" /> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-10-cm" /> <code value="Z00.129" /> </coding> </valueCodeableConcept> </example> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.type"> <path value="ExplanationOfBenefit.diagnosis.type" /> <comment value="If unspecified, assumed retrospective" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" /> </coding> </patternCodeableConcept> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.onAdmission"> <path value="ExplanationOfBenefit.diagnosis.onAdmission" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.diagnosis.packageCode"> <path value="ExplanationOfBenefit.diagnosis.packageCode" /> <short value="DRG" /> <alias value="drg" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.procedure"> <path value="ExplanationOfBenefit.procedure" /> <alias value="icd-procedure" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.procedure.id"> <path value="ExplanationOfBenefit.procedure.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.procedure.sequence"> <path value="ExplanationOfBenefit.procedure.sequence" /> <alias value="claim-line-number" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.procedure.date"> <path value="ExplanationOfBenefit.procedure.date" /> <short value="date of service" /> <comment value="When date of service is provided as a date range, use the starting ('from') date" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.procedure.procedure[x]"> <path value="ExplanationOfBenefit.procedure.procedure[x]" /> <label value="procedure" /> <short value="Procedure code" /> <comment value="Decimal places are preferred." /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures" /> </coding> </patternCodeableConcept> <example> <label value="Example EOB.procedure.procedureCodeableConcept ICD-10" /> <valueCodeableConcept> <coding> <system value="http://www.icd10data.com/icd10pcs" /> <code value="B241YZZ" /> </coding> </valueCodeableConcept> </example> <example> <label value="Example EOB.procedure.procedureCodeableConcept ICD-9" /> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-9-cm" /> <code value="47.01" /> </coding> </valueCodeableConcept> </example> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance"> <path value="ExplanationOfBenefit.insurance" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.id"> <path value="ExplanationOfBenefit.insurance.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.focal"> <path value="ExplanationOfBenefit.insurance.focal" /> <short value="Fixed: True" /> <fixedBoolean value="true" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.coverage"> <path value="ExplanationOfBenefit.insurance.coverage" /> <short value="Insurance coverage reference" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-insurance-coverage" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item"> <path value="ExplanationOfBenefit.item" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.id"> <path value="ExplanationOfBenefit.item.id" /> <comment value="usually line number" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.sequence"> <path value="ExplanationOfBenefit.item.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.revenue"> <path value="ExplanationOfBenefit.item.revenue" /> <short value="Revenue center code" /> <requirements value="required for institutional claims" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService"> <path value="ExplanationOfBenefit.item.productOrService" /> <alias value="cpt" /> <alias value="hcpcs" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <example> <label value="Example EOB.item.productOrService CPT" /> <valueCodeableConcept> <coding> <system value="http://www.nlm.nih.gov/research/umls/cpt" /> <code value="92551" /> </coding> </valueCodeableConcept> </example> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.modifier"> <path value="ExplanationOfBenefit.item.modifier" /> <short value="modifier to the product code" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.serviced[x]"> <path value="ExplanationOfBenefit.item.serviced[x]" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.quantity"> <path value="ExplanationOfBenefit.item.quantity" /> <short value="days / units" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.unitPrice"> <path value="ExplanationOfBenefit.item.unitPrice" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication"> <path value="ExplanationOfBenefit.item.adjudication" /> <slicing> <description value="slice by category" /> <rules value="open" /> </slicing> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <binding> <strength value="example" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-adjudication-category" /> </binding> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="benefit-amount" /> <short value="Line benefit amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="benefit" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:benefit-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:allowed-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="allowed-amount" /> <short value="Line allowed amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:allowed-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:allowed-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="allowed" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:allowed-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:copay-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="copay-amount" /> <short value="Line copay amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:copay-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:copay-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="copay" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:copay-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:eligible-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="eligible-amount" /> <short value="Line eligible amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:eligible-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:eligible-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="eligible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:eligible-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="deductible-amount" /> <short value="Line deductible amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="deductible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:deductible-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:member-liability-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="member-liability-amount" /> <short value="Line member liability amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:member-liability-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:member-liability-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" /> <code value="memberliability" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:member-liability-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:non-covered-amount"> <path value="ExplanationOfBenefit.item.adjudication" /> <sliceName value="non-covered-amount" /> <short value="Line non-covered amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:non-covered-amount.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication:non-covered-amount.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" /> <code value="noncovered" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.adjudication:non-covered-amount.amount"> <path value="ExplanationOfBenefit.item.adjudication.amount" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.adjudication"> <path value="ExplanationOfBenefit.adjudication" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.adjudication.id"> <path value="ExplanationOfBenefit.adjudication.id" /> <short value="set to category code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.adjudication.category"> <path value="ExplanationOfBenefit.adjudication.category" /> <short value="Amount type category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="preferred" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-adjudication-category" /> </binding> </element> <element id="ExplanationOfBenefit.adjudication.reason"> <path value="ExplanationOfBenefit.adjudication.reason" /> <short value="adjudication reason" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.adjudication.amount"> <path value="ExplanationOfBenefit.adjudication.amount" /> <short value="Financial amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total"> <path value="ExplanationOfBenefit.total" /> <slicing> <description value="slice by category" /> <rules value="open" /> </slicing> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="preferred" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-adjudication-category" /> </binding> </element> <element id="ExplanationOfBenefit.total.amount"> <path value="ExplanationOfBenefit.total.amount" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total:benefit-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="benefit-amount" /> <short value="Total benefit amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:benefit-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:benefit-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.total:copay-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="copay-amount" /> <short value="Total copay amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:copay-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:copay-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="copay" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.total:member-liability-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="member-liability-amount" /> <short value="Total member liability amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:member-liability-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:member-liability-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" /> <code value="memberliability" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.total:eligible-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="eligible-amount" /> <short value="Total eligible amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:eligible-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:eligible-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="eligible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.total:submitted-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="submitted-amount" /> <short value="Total submitted amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:submitted-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:submitted-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="submitted" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.total:deductible-amount"> <path value="ExplanationOfBenefit.total" /> <sliceName value="deductible-amount" /> <short value="Total deductible amount" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.total:deductible-amount.id"> <path value="ExplanationOfBenefit.total.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.total:deductible-amount.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/adjudication" /> <code value="deductible" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.benefitPeriod"> <path value="ExplanationOfBenefit.benefitPeriod" /> <mustSupport value="true" /> </element> </differential> </StructureDefinition>