Resource Profile: DXP ExplanationofBenefit
This profile builds upon the R4 Claim profile. It is used to convey information about the patient who received the services described on the claim.
Differential View of Profile Content
ExplanationOfBenefit | I | ExplanationOfBenefit | There are no (further) constraints on this element Element idExplanationOfBenefit Explanation of Benefit resource Alternate namesEOB DefinitionThis 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.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idExplanationOfBenefit.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idExplanationOfBenefit.implicitRules A set of rules under which this content was created DefinitionA 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. 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 it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idExplanationOfBenefit.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idExplanationOfBenefit.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. 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.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.identifier Business Identifier for the resource DefinitionA unique identifier assigned to this explanation of benefit. Allows EOBs to be distinguished and referenced.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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'. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the resource instance.
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type | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.type Category or discipline DefinitionThe category of claim, e.g. oral, pharmacy, vision, institutional, professional. Claim type determine the general sets of business rules applied for information requirements and adjudication. 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. The type or discipline-style of the claim.
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subType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.subType More granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Some jurisdictions need a finer grained claim type for routing and adjudication. This may contain the local bill type codes such as the US UB-04 bill type code. A more granular claim typecode.
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use | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.use claim | preauthorization | predetermination DefinitionA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. This element is required to understand the nature of the request for adjudication. Note that FHIR strings SHALL NOT exceed 1MB in size Complete, proposed, exploratory, other.
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patient | Σ I | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idExplanationOfBenefit.patient The recipient of the products and services DefinitionThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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billablePeriod | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.billablePeriod Relevant time frame for the claim DefinitionThe period for which charges are being submitted. A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. 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.
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created | Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.created Response creation date DefinitionThe date this resource was created. Need to record a timestamp for use by both the recipient and the issuer. This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
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enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idExplanationOfBenefit.enterer Author of the claim DefinitionIndividual who created the claim, predetermination or preauthorization. Some jurisdictions require the contact information for personnel completing claims. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole) Constraints
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insurer | Σ I | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurer Party responsible for reimbursement DefinitionThe party responsible for authorization, adjudication and reimbursement. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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provider | Σ I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.provider Party responsible for the claim DefinitionThe provider which is responsible for the claim, predetermination or preauthorization. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. Reference(Practitioner | PractitionerRole | Organization) Constraints
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priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.priority Desired processing urgency DefinitionThe provider-required urgency of processing the request. Typical values include: stat, routine deferred. The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. The timeliness with which processing is required: stat, normal, deferred.
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fundsReserveRequested | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserveRequested For whom to reserve funds Alternate namesFund pre-allocation DefinitionA code to indicate whether and for whom funds are to be reserved for future claims. 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. This field is only used for preauthorizations. For whom funds are to be reserved: (Patient, Provider, None).
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fundsReserve | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserve Funds reserved status DefinitionA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. For whom funds are to be reserved: (Patient, Provider, None).
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related | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.related Prior or corollary claims DefinitionOther claims which are related to this claim such as prior submissions or claims for related services or for the same event. For workplace or other accidents it is common to relate separate claims arising from the same event. For example, for the original treatment and follow-up exams.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.related.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.related.claim Reference to the related claim DefinitionReference to a related claim. For workplace or other accidents it is common to relate separate claims arising from the same event. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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relationship | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.related.relationship How the reference claim is related DefinitionA code to convey how the claims are related. Some insurers need a declaration of the type of relationship. For example, prior claim or umbrella. Relationship of this claim to a related Claim.
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reference | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.related.reference File or case reference DefinitionAn alternate organizational reference to the case or file to which this particular claim pertains. In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. For example, Property/Casualty insurer claim number or Workers Compensation case number.
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prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | There are no (further) constraints on this element Element idExplanationOfBenefit.prescription Prescription authorizing services or products DefinitionPrescription to support the dispensing of pharmacy, device or vision products. Required to authorize the dispensing of controlled substances and devices. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(MedicationRequest | VisionPrescription) Constraints
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originalPrescription | I | 0..1 | Reference(MedicationRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.originalPrescription Original prescription if superceded by fulfiller DefinitionOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. 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'.
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payee | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payee Recipient of benefits payable DefinitionThe party to be reimbursed for cost of the products and services according to the terms of the policy. The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.type Category of recipient DefinitionType of Party to be reimbursed: Subscriber, provider, other. Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. 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. A code for the party to be reimbursed.
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party | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.party Recipient reference DefinitionReference to the individual or organization to whom any payment will be made. Need to provide demographics if the payee is not 'subscriber' nor 'provider'. Not required if the payee is 'subscriber' or 'provider'. Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Constraints
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referral | I | 0..1 | Reference(ServiceRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.referral Treatment Referral DefinitionA reference to a referral resource. Some insurers require proof of referral to pay for services or to pay specialist rates for services. The referral resource which lists the date, practitioner, reason and other supporting information.
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facility | I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idExplanationOfBenefit.facility Servicing Facility DefinitionFacility where the services were provided. Insurance adjudication can be dependant on where services were delivered. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.claim Claim reference DefinitionThe business identifier for the instance of the adjudication request: claim predetermination or preauthorization. To provide a link to the original adjudication request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claimResponse | I | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idExplanationOfBenefit.claimResponse Claim response reference DefinitionThe business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. To provide a link to the original adjudication response. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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outcome | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.outcome queued | complete | error | partial DefinitionThe outcome of the claim, predetermination, or preauthorization processing. To advise the requestor of an overall processing outcome. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). The result of the claim processing.
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disposition | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.disposition Disposition Message DefinitionA human readable description of the status of the adjudication. Provided for user display. Note that FHIR strings SHALL NOT exceed 1MB in size
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRef Preauthorization reference DefinitionReference from the Insurer which is used in later communications which refers to this adjudication. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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preAuthRefPeriod | I | 0..* | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRefPeriod Preauthorization in-effect period DefinitionThe timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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careTeam | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam Care Team members DefinitionThe members of the team who provided the products and services. Common to identify the responsible and supporting practitioners.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.sequence Order of care team DefinitionA number to uniquely identify care team entries. Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. 32 bit number; for values larger than this, use decimal
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provider | I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.provider Practitioner or organization DefinitionMember of the team who provided the product or service. Often a regulatory requirement to specify the responsible provider. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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responsible | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.responsible Indicator of the lead practitioner DefinitionThe party who is billing and/or responsible for the claimed products or services. When multiple parties are present it is required to distinguish the lead or responsible individual. Responsible might not be required when there is only a single provider listed.
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role | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.role Function within the team DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. When multiple parties are present it is required to distinguish the roles performed by each member. Role might not be required when there is only a single provider listed. The role codes for the care team members.
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qualification | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.qualification Practitioner credential or specialization DefinitionThe qualification of the practitioner which is applicable for this service. Need to specify which qualification a provider is delivering the product or service under. 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. Provider professional qualifications.
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supportingInfo | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo Supporting information DefinitionAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Typically these information codes are required to support the services rendered or the adjudication of the services rendered. Often there are multiple jurisdiction specific valuesets which are required.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.sequence Information instance identifier DefinitionA number to uniquely identify supporting information entries. Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.category Classification of the supplied information DefinitionThe general class of the information supplied: information; exception; accident, employment; onset, etc. Required to group or associate information items with common characteristics. For example: admission information or prior treatments. This may contain a category for the local bill type codes. The valuset used for additional information category codes.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.code Type of information DefinitionSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. Required to identify the kind of additional information. This may contain the local bill type codes such as the US UB-04 bill type code. The valuset used for additional information codes.
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timing[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.timing[x] When it occurred DefinitionThe date when or period to which this information refers.
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timingDate | date | There are no (further) constraints on this element Data type | ||
timingPeriod | Period | There are no (further) constraints on this element Data type | ||
value[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.value[x] Data to be provided DefinitionAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. To convey the data content to be provided when the information is more than a simple code or period. 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.
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valueBoolean | boolean | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueReference | Reference(Resource) | There are no (further) constraints on this element Data type | ||
reason | 0..1 | Coding | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.reason Explanation for the information DefinitionProvides the reason in the situation where a reason code is required in addition to the content. Needed when the supporting information has both a date and amount/value and requires explanation. For example: the reason for the additional stay, or why a tooth is missing. Reason codes for the missing teeth.
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diagnosis | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis Pertinent diagnosis information DefinitionInformation about diagnoses relevant to the claim items. Required for the adjudication by provided context for the services and product listed.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.sequence Diagnosis instance identifier DefinitionA number to uniquely identify diagnosis entries. Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
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diagnosis[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.diagnosis[x] Nature of illness or problem DefinitionThe nature of illness or problem in a coded form or as a reference to an external defined Condition. Provides health context for the evaluation of the products and/or services. ICD10 Diagnostic codes.
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diagnosisCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
diagnosisReference | Reference(Condition) | There are no (further) constraints on this element Data type | ||
type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.type Timing or nature of the diagnosis DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. For example: admitting, primary, secondary, discharge. The type of the diagnosis: admitting, principal, discharge.
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onAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.onAdmission Present on admission DefinitionIndication of whether the diagnosis was present on admission to a facility. Many systems need to understand for adjudication if the diagnosis was present a time of admission. 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. Present on admission.
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packageCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.packageCode Package billing code DefinitionA 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. 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. For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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. The DRG codes associated with the diagnosis.
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procedure | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure Clinical procedures performed DefinitionProcedures performed on the patient relevant to the billing items with the claim. The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.sequence Procedure instance identifier DefinitionA number to uniquely identify procedure entries. Necessary to provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.type Category of Procedure DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. 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. Example procedure type codes.
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date | 0..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.date When the procedure was performed DefinitionDate and optionally time the procedure was performed. Required for auditing purposes.
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procedure[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.procedure[x] Specific clinical procedure DefinitionThe code or reference to a Procedure resource which identifies the clinical intervention performed. This identifies the actual clinical procedure. ICD10 Procedure codes.
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procedureCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
procedureReference | Reference(Procedure) | There are no (further) constraints on this element Data type | ||
udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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precedence | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.precedence Precedence (primary, secondary, etc.) DefinitionThis indicates the relative order of a series of EOBs related to different coverages for the same suite of services. Needed to coordinate between multiple EOBs for the same suite of services. 32 bit number; for values larger than this, use decimal
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insurance | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance Patient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim. At least one insurer is required for a claim to be a claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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focal | Σ | 1..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.focal Coverage to be used for adjudication DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. To identify which coverage in the list is being used to adjudicate this claim. 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.
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coverage | Σ I | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.coverage Insurance information DefinitionReference 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. Required to allow the adjudicator to locate the correct policy and history within their information system. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.preAuthRef Prior authorization reference number DefinitionReference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization. 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.
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accident | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.accident Details of the event DefinitionDetails of a accident which resulted in injuries which required the products and services listed in the claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.date When the incident occurred DefinitionDate of an accident event related to the products and services contained in the claim. Required for audit purposes and adjudication. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
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type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.type The nature of the accident DefinitionThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. Coverage may be dependant on the type of accident. 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. Type of accident: work place, auto, etc.
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location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.location[x] Where the event occurred DefinitionThe physical location of the accident event. Required for audit purposes and determination of applicable insurance liability.
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locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
item | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item Product or service provided DefinitionA 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. The items to be processed for adjudication.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.sequence Item instance identifier DefinitionA number to uniquely identify item entries. Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. 32 bit number; for values larger than this, use decimal
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careTeamSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.careTeamSequence Applicable care team members DefinitionCare team members related to this service or product. Need to identify the individuals and their roles in the provision of the product or service. 32 bit number; for values larger than this, use decimal
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diagnosisSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.diagnosisSequence Applicable diagnoses DefinitionDiagnoses applicable for this service or product. Need to related the product or service to the associated diagnoses. 32 bit number; for values larger than this, use decimal
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procedureSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.procedureSequence Applicable procedures DefinitionProcedures applicable for this service or product. Need to provide any listed specific procedures to support the product or service being claimed. 32 bit number; for values larger than this, use decimal
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informationSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.informationSequence Applicable exception and supporting information DefinitionExceptions, special conditions and supporting information applicable for this service or product. Need to reference the supporting information items that relate directly to this product or service. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifier Product or service billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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encounter | I | 0..* | Reference(Encounter) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.encounter Encounters related to this billed item DefinitionA billed item may include goods or services provided in multiple encounters. Used in some jurisdictions to link clinical events to claim items. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication Adjudication details DefinitionIf 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. The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.category Type of adjudication information DefinitionA 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. Needed to enable understanding of the context of the other information in the adjudication. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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reason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.reason Explanation of adjudication outcome DefinitionA code supporting the understanding of the adjudication result and explaining variance from expected amount. To support understanding of variance from adjudication expectations. For example, may indicate that the funds for this benefit type have been exhausted. Adjudication reason codes.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.amount Monetary amount DefinitionMonetary amount associated with the category. Most adjuciation categories convey a monetary amount. For example, amount submitted, eligible amount, co-payment, and benefit payable.
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value | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.value Non-monitary value DefinitionA non-monetary value associated with the category. Mutually exclusive to the amount element above. Some adjudication categories convey a percentage or a fixed value. For example: eligible percentage or co-payment percentage.
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detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail Additional items DefinitionSecond-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.adjudication Detail level adjudication details DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail Additional items DefinitionThird-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.adjudication Subdetail level adjudication details DefinitionThe adjudication results. | |
addItem | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem Insurer added line items DefinitionThe first-tier service adjudications for payor added product or service lines. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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itemSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.itemSequence Item sequence number DefinitionClaim items which this service line is intended to replace. Provides references to the claim items. 32 bit number; for values larger than this, use decimal
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detailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detailSequence Detail sequence number DefinitionThe sequence number of the details within the claim item which this line is intended to replace. Provides references to the claim details within the claim item. 32 bit number; for values larger than this, use decimal
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subDetailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subDetailSequence Subdetail sequence number DefinitionThe sequence number of the sub-details woithin the details within the claim item which this line is intended to replace. Provides references to the claim sub-details within the claim detail. 32 bit number; for values larger than this, use decimal
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provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.provider Authorized providers DefinitionThe providers who are authorized for the services rendered to the patient. Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.adjudication Added items adjudication DefinitionThe adjudication results. | |
detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail Insurer added line items DefinitionThe second-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.adjudication Added items adjudication DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail Insurer added line items DefinitionThe third-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.adjudication Added items adjudication DefinitionThe adjudication results. | |
adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.adjudication Header-level adjudication DefinitionThe adjudication results which are presented at the header level rather than at the line-item or add-item levels. Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | |
total | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.total Adjudication totals DefinitionCategorized monetary totals for the adjudication. To provide the requestor with financial totals by category for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.total.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.total.category Type of adjudication information DefinitionA 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. Needed to convey the type of total provided. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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amount | Σ | 1..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.total.amount Financial total for the category DefinitionMonetary total amount associated with the category. Needed to convey the total monetary amount.
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payment | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payment Payment Details DefinitionPayment details for the adjudication of the claim. Needed to convey references to the financial instrument that has been used if payment has been made.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.type Partial or complete payment DefinitionWhether this represents partial or complete payment of the benefits payable. To advise the requestor when the insurer believes all payments to have been completed. 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. The type (partial, complete) of the payment.
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adjustment | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustment Payment adjustment for non-claim issues DefinitionTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. To advise the requestor of adjustments applied to the payment. 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.
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adjustmentReason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustmentReason Explanation for the variance DefinitionReason for the payment adjustment. Needed to clarify the monetary adjustment. 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. Payment Adjustment reason codes.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.date Expected date of payment DefinitionEstimated date the payment will be issued or the actual issue date of payment. To advise the payee when payment can be expected.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.amount Payable amount after adjustment DefinitionBenefits payable less any payment adjustment. Needed to provide the actual payment amount.
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identifier | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.identifier Business identifier for the payment DefinitionIssuer's unique identifier for the payment instrument. Enable the receiver to reconcile when payment received. For example: EFT number or check number.
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formCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.formCode Printed form identifier DefinitionA code for the form to be used for printing the content. Needed to specify the specific form used for producing output for this response. May be needed to identify specific jurisdictional forms. The forms codes.
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form | I | 0..1 | Attachment | There are no (further) constraints on this element Element idExplanationOfBenefit.form Printed reference or actual form DefinitionThe actual form, by reference or inclusion, for printing the content or an EOB. Needed to include the specific form used for producing output for this response. Needed to permit insurers to include the actual form.
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processNote | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote Note concerning adjudication DefinitionA note that describes or explains adjudication results in a human readable form. Provides the insurer specific textual explanations associated with the processing.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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number | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.number Note instance identifier DefinitionA number to uniquely identify a note entry. Necessary to provide a mechanism to link from adjudications. 32 bit number; for values larger than this, use decimal
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type | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.type display | print | printoper DefinitionThe business purpose of the note text. To convey the expectation for when the text is used. Note that FHIR strings SHALL NOT exceed 1MB in size The presentation types of notes.
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text | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.text Note explanatory text DefinitionThe explanation or description associated with the processing. Required to provide human readable explanation. Note that FHIR strings SHALL NOT exceed 1MB in size
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language | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.language Language of the text DefinitionA code to define the language used in the text of the note. Note text may vary from the resource defined language. Only required if the language is different from the resource language. A human language.
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benefitPeriod | I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitPeriod When the benefits are applicable DefinitionThe term of the benefits documented in this response. Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. Not applicable when use=claim.
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benefitBalance | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance Balance by Benefit Category DefinitionBalance by Benefit Category.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. Needed to convey the category of service or product for which eligibility is sought. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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excluded | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.excluded Excluded from the plan DefinitionTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. Needed to identify items that are specifically excluded from the coverage.
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name | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.name Short name for the benefit DefinitionA short name or tag for the benefit. Required to align with other plan names. For example: MED01, or DENT2.
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description | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.description Description of the benefit or services covered DefinitionA richer description of the benefit or services covered. Needed for human readable reference. For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
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network | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.network In or out of network DefinitionIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. Needed as in or out of network providers are treated differently under the coverage. 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. Code to classify in or out of network services.
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unit | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.unit Individual or family DefinitionIndicates if the benefits apply to an individual or to the family. Needed for the understanding of the benefits. 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. Unit covered/serviced - individual or family.
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term | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.term Annual or lifetime DefinitionThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. Needed for the understanding of the benefits. 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. Coverage unit - annual, lifetime.
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financial | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial Benefit Summary DefinitionBenefits Used to date.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.type Benefit classification DefinitionClassification of benefit being provided. Needed to convey the nature of the benefit. For example: deductible, visits, benefit amount. Deductable, visits, co-pay, etc.
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allowed[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.allowed[x] Benefits allowed DefinitionThe quantity of the benefit which is permitted under the coverage. Needed to convey the benefits offered under the coverage.
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allowedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
allowedString | string | There are no (further) constraints on this element Data type | ||
allowedMoney | Money | There are no (further) constraints on this element Data type | ||
used[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.used[x] Benefits used DefinitionThe quantity of the benefit which have been consumed to date. Needed to convey the benefits consumed to date.
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usedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
usedMoney | Money | There are no (further) constraints on this element Data type |
Hybrid View of Profile Content
ExplanationOfBenefit | I | ExplanationOfBenefit | There are no (further) constraints on this element Element idExplanationOfBenefit Explanation of Benefit resource Alternate namesEOB DefinitionThis 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.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idExplanationOfBenefit.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idExplanationOfBenefit.implicitRules A set of rules under which this content was created DefinitionA 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. 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 it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idExplanationOfBenefit.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idExplanationOfBenefit.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. 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.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.identifier Business Identifier for the resource DefinitionA unique identifier assigned to this explanation of benefit. Allows EOBs to be distinguished and referenced.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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'. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the resource instance.
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type | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.type Category or discipline DefinitionThe category of claim, e.g. oral, pharmacy, vision, institutional, professional. Claim type determine the general sets of business rules applied for information requirements and adjudication. 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. The type or discipline-style of the claim.
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subType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.subType More granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Some jurisdictions need a finer grained claim type for routing and adjudication. This may contain the local bill type codes such as the US UB-04 bill type code. A more granular claim typecode.
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use | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.use claim | preauthorization | predetermination DefinitionA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. This element is required to understand the nature of the request for adjudication. Note that FHIR strings SHALL NOT exceed 1MB in size Complete, proposed, exploratory, other.
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patient | Σ I | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idExplanationOfBenefit.patient The recipient of the products and services DefinitionThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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billablePeriod | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.billablePeriod Relevant time frame for the claim DefinitionThe period for which charges are being submitted. A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. 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.
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created | Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.created Response creation date DefinitionThe date this resource was created. Need to record a timestamp for use by both the recipient and the issuer. This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
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enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idExplanationOfBenefit.enterer Author of the claim DefinitionIndividual who created the claim, predetermination or preauthorization. Some jurisdictions require the contact information for personnel completing claims. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole) Constraints
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insurer | Σ I | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurer Party responsible for reimbursement DefinitionThe party responsible for authorization, adjudication and reimbursement. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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provider | Σ I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.provider Party responsible for the claim DefinitionThe provider which is responsible for the claim, predetermination or preauthorization. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. Reference(Practitioner | PractitionerRole | Organization) Constraints
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priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.priority Desired processing urgency DefinitionThe provider-required urgency of processing the request. Typical values include: stat, routine deferred. The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. The timeliness with which processing is required: stat, normal, deferred.
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fundsReserveRequested | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserveRequested For whom to reserve funds Alternate namesFund pre-allocation DefinitionA code to indicate whether and for whom funds are to be reserved for future claims. 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. This field is only used for preauthorizations. For whom funds are to be reserved: (Patient, Provider, None).
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fundsReserve | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserve Funds reserved status DefinitionA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. For whom funds are to be reserved: (Patient, Provider, None).
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related | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.related Prior or corollary claims DefinitionOther claims which are related to this claim such as prior submissions or claims for related services or for the same event. For workplace or other accidents it is common to relate separate claims arising from the same event. For example, for the original treatment and follow-up exams.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.related.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.related.claim Reference to the related claim DefinitionReference to a related claim. For workplace or other accidents it is common to relate separate claims arising from the same event. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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relationship | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.related.relationship How the reference claim is related DefinitionA code to convey how the claims are related. Some insurers need a declaration of the type of relationship. For example, prior claim or umbrella. Relationship of this claim to a related Claim.
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reference | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.related.reference File or case reference DefinitionAn alternate organizational reference to the case or file to which this particular claim pertains. In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. For example, Property/Casualty insurer claim number or Workers Compensation case number.
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prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | There are no (further) constraints on this element Element idExplanationOfBenefit.prescription Prescription authorizing services or products DefinitionPrescription to support the dispensing of pharmacy, device or vision products. Required to authorize the dispensing of controlled substances and devices. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(MedicationRequest | VisionPrescription) Constraints
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originalPrescription | I | 0..1 | Reference(MedicationRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.originalPrescription Original prescription if superceded by fulfiller DefinitionOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. 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'.
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payee | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payee Recipient of benefits payable DefinitionThe party to be reimbursed for cost of the products and services according to the terms of the policy. The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.type Category of recipient DefinitionType of Party to be reimbursed: Subscriber, provider, other. Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. 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. A code for the party to be reimbursed.
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party | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.party Recipient reference DefinitionReference to the individual or organization to whom any payment will be made. Need to provide demographics if the payee is not 'subscriber' nor 'provider'. Not required if the payee is 'subscriber' or 'provider'. Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Constraints
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referral | I | 0..1 | Reference(ServiceRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.referral Treatment Referral DefinitionA reference to a referral resource. Some insurers require proof of referral to pay for services or to pay specialist rates for services. The referral resource which lists the date, practitioner, reason and other supporting information.
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facility | I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idExplanationOfBenefit.facility Servicing Facility DefinitionFacility where the services were provided. Insurance adjudication can be dependant on where services were delivered. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.claim Claim reference DefinitionThe business identifier for the instance of the adjudication request: claim predetermination or preauthorization. To provide a link to the original adjudication request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claimResponse | I | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idExplanationOfBenefit.claimResponse Claim response reference DefinitionThe business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. To provide a link to the original adjudication response. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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outcome | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.outcome queued | complete | error | partial DefinitionThe outcome of the claim, predetermination, or preauthorization processing. To advise the requestor of an overall processing outcome. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). The result of the claim processing.
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disposition | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.disposition Disposition Message DefinitionA human readable description of the status of the adjudication. Provided for user display. Note that FHIR strings SHALL NOT exceed 1MB in size
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRef Preauthorization reference DefinitionReference from the Insurer which is used in later communications which refers to this adjudication. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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preAuthRefPeriod | I | 0..* | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRefPeriod Preauthorization in-effect period DefinitionThe timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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careTeam | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam Care Team members DefinitionThe members of the team who provided the products and services. Common to identify the responsible and supporting practitioners.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.sequence Order of care team DefinitionA number to uniquely identify care team entries. Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. 32 bit number; for values larger than this, use decimal
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provider | I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.provider Practitioner or organization DefinitionMember of the team who provided the product or service. Often a regulatory requirement to specify the responsible provider. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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responsible | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.responsible Indicator of the lead practitioner DefinitionThe party who is billing and/or responsible for the claimed products or services. When multiple parties are present it is required to distinguish the lead or responsible individual. Responsible might not be required when there is only a single provider listed.
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role | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.role Function within the team DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. When multiple parties are present it is required to distinguish the roles performed by each member. Role might not be required when there is only a single provider listed. The role codes for the care team members.
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qualification | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.qualification Practitioner credential or specialization DefinitionThe qualification of the practitioner which is applicable for this service. Need to specify which qualification a provider is delivering the product or service under. 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. Provider professional qualifications.
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supportingInfo | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo Supporting information DefinitionAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Typically these information codes are required to support the services rendered or the adjudication of the services rendered. Often there are multiple jurisdiction specific valuesets which are required.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.sequence Information instance identifier DefinitionA number to uniquely identify supporting information entries. Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.category Classification of the supplied information DefinitionThe general class of the information supplied: information; exception; accident, employment; onset, etc. Required to group or associate information items with common characteristics. For example: admission information or prior treatments. This may contain a category for the local bill type codes. The valuset used for additional information category codes.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.code Type of information DefinitionSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. Required to identify the kind of additional information. This may contain the local bill type codes such as the US UB-04 bill type code. The valuset used for additional information codes.
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timing[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.timing[x] When it occurred DefinitionThe date when or period to which this information refers.
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timingDate | date | There are no (further) constraints on this element Data type | ||
timingPeriod | Period | There are no (further) constraints on this element Data type | ||
value[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.value[x] Data to be provided DefinitionAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. To convey the data content to be provided when the information is more than a simple code or period. 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.
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valueBoolean | boolean | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueReference | Reference(Resource) | There are no (further) constraints on this element Data type | ||
reason | 0..1 | Coding | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.reason Explanation for the information DefinitionProvides the reason in the situation where a reason code is required in addition to the content. Needed when the supporting information has both a date and amount/value and requires explanation. For example: the reason for the additional stay, or why a tooth is missing. Reason codes for the missing teeth.
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diagnosis | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis Pertinent diagnosis information DefinitionInformation about diagnoses relevant to the claim items. Required for the adjudication by provided context for the services and product listed.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.sequence Diagnosis instance identifier DefinitionA number to uniquely identify diagnosis entries. Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
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diagnosis[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.diagnosis[x] Nature of illness or problem DefinitionThe nature of illness or problem in a coded form or as a reference to an external defined Condition. Provides health context for the evaluation of the products and/or services. ICD10 Diagnostic codes.
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diagnosisCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
diagnosisReference | Reference(Condition) | There are no (further) constraints on this element Data type | ||
type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.type Timing or nature of the diagnosis DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. For example: admitting, primary, secondary, discharge. The type of the diagnosis: admitting, principal, discharge.
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onAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.onAdmission Present on admission DefinitionIndication of whether the diagnosis was present on admission to a facility. Many systems need to understand for adjudication if the diagnosis was present a time of admission. 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. Present on admission.
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packageCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.packageCode Package billing code DefinitionA 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. 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. For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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. The DRG codes associated with the diagnosis.
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procedure | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure Clinical procedures performed DefinitionProcedures performed on the patient relevant to the billing items with the claim. The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.sequence Procedure instance identifier DefinitionA number to uniquely identify procedure entries. Necessary to provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.type Category of Procedure DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. 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. Example procedure type codes.
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date | 0..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.date When the procedure was performed DefinitionDate and optionally time the procedure was performed. Required for auditing purposes.
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procedure[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.procedure[x] Specific clinical procedure DefinitionThe code or reference to a Procedure resource which identifies the clinical intervention performed. This identifies the actual clinical procedure. ICD10 Procedure codes.
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procedureCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
procedureReference | Reference(Procedure) | There are no (further) constraints on this element Data type | ||
udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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precedence | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.precedence Precedence (primary, secondary, etc.) DefinitionThis indicates the relative order of a series of EOBs related to different coverages for the same suite of services. Needed to coordinate between multiple EOBs for the same suite of services. 32 bit number; for values larger than this, use decimal
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insurance | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance Patient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim. At least one insurer is required for a claim to be a claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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focal | Σ | 1..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.focal Coverage to be used for adjudication DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. To identify which coverage in the list is being used to adjudicate this claim. 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.
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coverage | Σ I | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.coverage Insurance information DefinitionReference 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. Required to allow the adjudicator to locate the correct policy and history within their information system. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.preAuthRef Prior authorization reference number DefinitionReference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization. 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.
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accident | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.accident Details of the event DefinitionDetails of a accident which resulted in injuries which required the products and services listed in the claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.date When the incident occurred DefinitionDate of an accident event related to the products and services contained in the claim. Required for audit purposes and adjudication. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
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type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.type The nature of the accident DefinitionThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. Coverage may be dependant on the type of accident. 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. Type of accident: work place, auto, etc.
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location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.location[x] Where the event occurred DefinitionThe physical location of the accident event. Required for audit purposes and determination of applicable insurance liability.
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locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
item | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item Product or service provided DefinitionA 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. The items to be processed for adjudication.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.sequence Item instance identifier DefinitionA number to uniquely identify item entries. Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. 32 bit number; for values larger than this, use decimal
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careTeamSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.careTeamSequence Applicable care team members DefinitionCare team members related to this service or product. Need to identify the individuals and their roles in the provision of the product or service. 32 bit number; for values larger than this, use decimal
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diagnosisSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.diagnosisSequence Applicable diagnoses DefinitionDiagnoses applicable for this service or product. Need to related the product or service to the associated diagnoses. 32 bit number; for values larger than this, use decimal
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procedureSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.procedureSequence Applicable procedures DefinitionProcedures applicable for this service or product. Need to provide any listed specific procedures to support the product or service being claimed. 32 bit number; for values larger than this, use decimal
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informationSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.informationSequence Applicable exception and supporting information DefinitionExceptions, special conditions and supporting information applicable for this service or product. Need to reference the supporting information items that relate directly to this product or service. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifier Product or service billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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encounter | I | 0..* | Reference(Encounter) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.encounter Encounters related to this billed item DefinitionA billed item may include goods or services provided in multiple encounters. Used in some jurisdictions to link clinical events to claim items. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication Adjudication details DefinitionIf 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. The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.category Type of adjudication information DefinitionA 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. Needed to enable understanding of the context of the other information in the adjudication. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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reason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.reason Explanation of adjudication outcome DefinitionA code supporting the understanding of the adjudication result and explaining variance from expected amount. To support understanding of variance from adjudication expectations. For example, may indicate that the funds for this benefit type have been exhausted. Adjudication reason codes.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.amount Monetary amount DefinitionMonetary amount associated with the category. Most adjuciation categories convey a monetary amount. For example, amount submitted, eligible amount, co-payment, and benefit payable.
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value | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.value Non-monitary value DefinitionA non-monetary value associated with the category. Mutually exclusive to the amount element above. Some adjudication categories convey a percentage or a fixed value. For example: eligible percentage or co-payment percentage.
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detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail Additional items DefinitionSecond-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.adjudication Detail level adjudication details DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail Additional items DefinitionThird-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.adjudication Subdetail level adjudication details DefinitionThe adjudication results. | |
addItem | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem Insurer added line items DefinitionThe first-tier service adjudications for payor added product or service lines. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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itemSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.itemSequence Item sequence number DefinitionClaim items which this service line is intended to replace. Provides references to the claim items. 32 bit number; for values larger than this, use decimal
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detailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detailSequence Detail sequence number DefinitionThe sequence number of the details within the claim item which this line is intended to replace. Provides references to the claim details within the claim item. 32 bit number; for values larger than this, use decimal
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subDetailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subDetailSequence Subdetail sequence number DefinitionThe sequence number of the sub-details woithin the details within the claim item which this line is intended to replace. Provides references to the claim sub-details within the claim detail. 32 bit number; for values larger than this, use decimal
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provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.provider Authorized providers DefinitionThe providers who are authorized for the services rendered to the patient. Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.adjudication Added items adjudication DefinitionThe adjudication results. | |
detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail Insurer added line items DefinitionThe second-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.adjudication Added items adjudication DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail Insurer added line items DefinitionThe third-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.adjudication Added items adjudication DefinitionThe adjudication results. | |
adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.adjudication Header-level adjudication DefinitionThe adjudication results which are presented at the header level rather than at the line-item or add-item levels. Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | |
total | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.total Adjudication totals DefinitionCategorized monetary totals for the adjudication. To provide the requestor with financial totals by category for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.total.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.total.category Type of adjudication information DefinitionA 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. Needed to convey the type of total provided. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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amount | Σ | 1..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.total.amount Financial total for the category DefinitionMonetary total amount associated with the category. Needed to convey the total monetary amount.
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payment | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payment Payment Details DefinitionPayment details for the adjudication of the claim. Needed to convey references to the financial instrument that has been used if payment has been made.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.type Partial or complete payment DefinitionWhether this represents partial or complete payment of the benefits payable. To advise the requestor when the insurer believes all payments to have been completed. 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. The type (partial, complete) of the payment.
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adjustment | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustment Payment adjustment for non-claim issues DefinitionTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. To advise the requestor of adjustments applied to the payment. 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.
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adjustmentReason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustmentReason Explanation for the variance DefinitionReason for the payment adjustment. Needed to clarify the monetary adjustment. 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. Payment Adjustment reason codes.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.date Expected date of payment DefinitionEstimated date the payment will be issued or the actual issue date of payment. To advise the payee when payment can be expected.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.amount Payable amount after adjustment DefinitionBenefits payable less any payment adjustment. Needed to provide the actual payment amount.
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identifier | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.identifier Business identifier for the payment DefinitionIssuer's unique identifier for the payment instrument. Enable the receiver to reconcile when payment received. For example: EFT number or check number.
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formCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.formCode Printed form identifier DefinitionA code for the form to be used for printing the content. Needed to specify the specific form used for producing output for this response. May be needed to identify specific jurisdictional forms. The forms codes.
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form | I | 0..1 | Attachment | There are no (further) constraints on this element Element idExplanationOfBenefit.form Printed reference or actual form DefinitionThe actual form, by reference or inclusion, for printing the content or an EOB. Needed to include the specific form used for producing output for this response. Needed to permit insurers to include the actual form.
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processNote | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote Note concerning adjudication DefinitionA note that describes or explains adjudication results in a human readable form. Provides the insurer specific textual explanations associated with the processing.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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number | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.number Note instance identifier DefinitionA number to uniquely identify a note entry. Necessary to provide a mechanism to link from adjudications. 32 bit number; for values larger than this, use decimal
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type | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.type display | print | printoper DefinitionThe business purpose of the note text. To convey the expectation for when the text is used. Note that FHIR strings SHALL NOT exceed 1MB in size The presentation types of notes.
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text | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.text Note explanatory text DefinitionThe explanation or description associated with the processing. Required to provide human readable explanation. Note that FHIR strings SHALL NOT exceed 1MB in size
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language | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.language Language of the text DefinitionA code to define the language used in the text of the note. Note text may vary from the resource defined language. Only required if the language is different from the resource language. A human language.
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benefitPeriod | I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitPeriod When the benefits are applicable DefinitionThe term of the benefits documented in this response. Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. Not applicable when use=claim.
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benefitBalance | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance Balance by Benefit Category DefinitionBalance by Benefit Category.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. Needed to convey the category of service or product for which eligibility is sought. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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excluded | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.excluded Excluded from the plan DefinitionTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. Needed to identify items that are specifically excluded from the coverage.
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name | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.name Short name for the benefit DefinitionA short name or tag for the benefit. Required to align with other plan names. For example: MED01, or DENT2.
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description | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.description Description of the benefit or services covered DefinitionA richer description of the benefit or services covered. Needed for human readable reference. For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
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network | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.network In or out of network DefinitionIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. Needed as in or out of network providers are treated differently under the coverage. 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. Code to classify in or out of network services.
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unit | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.unit Individual or family DefinitionIndicates if the benefits apply to an individual or to the family. Needed for the understanding of the benefits. 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. Unit covered/serviced - individual or family.
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term | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.term Annual or lifetime DefinitionThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. Needed for the understanding of the benefits. 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. Coverage unit - annual, lifetime.
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financial | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial Benefit Summary DefinitionBenefits Used to date.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.type Benefit classification DefinitionClassification of benefit being provided. Needed to convey the nature of the benefit. For example: deductible, visits, benefit amount. Deductable, visits, co-pay, etc.
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allowed[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.allowed[x] Benefits allowed DefinitionThe quantity of the benefit which is permitted under the coverage. Needed to convey the benefits offered under the coverage.
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allowedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
allowedString | string | There are no (further) constraints on this element Data type | ||
allowedMoney | Money | There are no (further) constraints on this element Data type | ||
used[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.used[x] Benefits used DefinitionThe quantity of the benefit which have been consumed to date. Needed to convey the benefits consumed to date.
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usedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
usedMoney | Money | There are no (further) constraints on this element Data type |
Snapshot View of Profile Content
ExplanationOfBenefit | I | ExplanationOfBenefit | There are no (further) constraints on this element Element idExplanationOfBenefit Explanation of Benefit resource Alternate namesEOB DefinitionThis 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.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idExplanationOfBenefit.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idExplanationOfBenefit.implicitRules A set of rules under which this content was created DefinitionA 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. 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 it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idExplanationOfBenefit.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idExplanationOfBenefit.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. 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.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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 manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.identifier Business Identifier for the resource DefinitionA unique identifier assigned to this explanation of benefit. Allows EOBs to be distinguished and referenced.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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'. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the resource instance.
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type | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.type Category or discipline DefinitionThe category of claim, e.g. oral, pharmacy, vision, institutional, professional. Claim type determine the general sets of business rules applied for information requirements and adjudication. 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. The type or discipline-style of the claim.
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subType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.subType More granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Some jurisdictions need a finer grained claim type for routing and adjudication. This may contain the local bill type codes such as the US UB-04 bill type code. A more granular claim typecode.
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use | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.use claim | preauthorization | predetermination DefinitionA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. This element is required to understand the nature of the request for adjudication. Note that FHIR strings SHALL NOT exceed 1MB in size Complete, proposed, exploratory, other.
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patient | Σ I | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idExplanationOfBenefit.patient The recipient of the products and services DefinitionThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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billablePeriod | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.billablePeriod Relevant time frame for the claim DefinitionThe period for which charges are being submitted. A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. 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.
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created | Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.created Response creation date DefinitionThe date this resource was created. Need to record a timestamp for use by both the recipient and the issuer. This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
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enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idExplanationOfBenefit.enterer Author of the claim DefinitionIndividual who created the claim, predetermination or preauthorization. Some jurisdictions require the contact information for personnel completing claims. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole) Constraints
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insurer | Σ I | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurer Party responsible for reimbursement DefinitionThe party responsible for authorization, adjudication and reimbursement. 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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provider | Σ I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.provider Party responsible for the claim DefinitionThe provider which is responsible for the claim, predetermination or preauthorization. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. Reference(Practitioner | PractitionerRole | Organization) Constraints
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priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.priority Desired processing urgency DefinitionThe provider-required urgency of processing the request. Typical values include: stat, routine deferred. The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. The timeliness with which processing is required: stat, normal, deferred.
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fundsReserveRequested | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserveRequested For whom to reserve funds Alternate namesFund pre-allocation DefinitionA code to indicate whether and for whom funds are to be reserved for future claims. 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. This field is only used for preauthorizations. For whom funds are to be reserved: (Patient, Provider, None).
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fundsReserve | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.fundsReserve Funds reserved status DefinitionA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. For whom funds are to be reserved: (Patient, Provider, None).
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related | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.related Prior or corollary claims DefinitionOther claims which are related to this claim such as prior submissions or claims for related services or for the same event. For workplace or other accidents it is common to relate separate claims arising from the same event. For example, for the original treatment and follow-up exams.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.related.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.related.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.related.claim Reference to the related claim DefinitionReference to a related claim. For workplace or other accidents it is common to relate separate claims arising from the same event. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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relationship | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.related.relationship How the reference claim is related DefinitionA code to convey how the claims are related. Some insurers need a declaration of the type of relationship. For example, prior claim or umbrella. Relationship of this claim to a related Claim.
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reference | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.related.reference File or case reference DefinitionAn alternate organizational reference to the case or file to which this particular claim pertains. In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. For example, Property/Casualty insurer claim number or Workers Compensation case number.
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prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | There are no (further) constraints on this element Element idExplanationOfBenefit.prescription Prescription authorizing services or products DefinitionPrescription to support the dispensing of pharmacy, device or vision products. Required to authorize the dispensing of controlled substances and devices. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(MedicationRequest | VisionPrescription) Constraints
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originalPrescription | I | 0..1 | Reference(MedicationRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.originalPrescription Original prescription if superceded by fulfiller DefinitionOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. 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'.
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payee | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payee Recipient of benefits payable DefinitionThe party to be reimbursed for cost of the products and services according to the terms of the policy. The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.type Category of recipient DefinitionType of Party to be reimbursed: Subscriber, provider, other. Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. 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. A code for the party to be reimbursed.
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party | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | There are no (further) constraints on this element Element idExplanationOfBenefit.payee.party Recipient reference DefinitionReference to the individual or organization to whom any payment will be made. Need to provide demographics if the payee is not 'subscriber' nor 'provider'. Not required if the payee is 'subscriber' or 'provider'. Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Constraints
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referral | I | 0..1 | Reference(ServiceRequest) | There are no (further) constraints on this element Element idExplanationOfBenefit.referral Treatment Referral DefinitionA reference to a referral resource. Some insurers require proof of referral to pay for services or to pay specialist rates for services. The referral resource which lists the date, practitioner, reason and other supporting information.
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facility | I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idExplanationOfBenefit.facility Servicing Facility DefinitionFacility where the services were provided. Insurance adjudication can be dependant on where services were delivered. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claim | I | 0..1 | Reference(Claim) | There are no (further) constraints on this element Element idExplanationOfBenefit.claim Claim reference DefinitionThe business identifier for the instance of the adjudication request: claim predetermination or preauthorization. To provide a link to the original adjudication request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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claimResponse | I | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idExplanationOfBenefit.claimResponse Claim response reference DefinitionThe business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. To provide a link to the original adjudication response. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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outcome | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.outcome queued | complete | error | partial DefinitionThe outcome of the claim, predetermination, or preauthorization processing. To advise the requestor of an overall processing outcome. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). The result of the claim processing.
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disposition | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.disposition Disposition Message DefinitionA human readable description of the status of the adjudication. Provided for user display. Note that FHIR strings SHALL NOT exceed 1MB in size
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRef Preauthorization reference DefinitionReference from the Insurer which is used in later communications which refers to this adjudication. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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preAuthRefPeriod | I | 0..* | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.preAuthRefPeriod Preauthorization in-effect period DefinitionThe timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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careTeam | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam Care Team members DefinitionThe members of the team who provided the products and services. Common to identify the responsible and supporting practitioners.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.sequence Order of care team DefinitionA number to uniquely identify care team entries. Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. 32 bit number; for values larger than this, use decimal
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provider | I | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.provider Practitioner or organization DefinitionMember of the team who provided the product or service. Often a regulatory requirement to specify the responsible provider. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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responsible | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.responsible Indicator of the lead practitioner DefinitionThe party who is billing and/or responsible for the claimed products or services. When multiple parties are present it is required to distinguish the lead or responsible individual. Responsible might not be required when there is only a single provider listed.
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role | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.role Function within the team DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. When multiple parties are present it is required to distinguish the roles performed by each member. Role might not be required when there is only a single provider listed. The role codes for the care team members.
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qualification | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.careTeam.qualification Practitioner credential or specialization DefinitionThe qualification of the practitioner which is applicable for this service. Need to specify which qualification a provider is delivering the product or service under. 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. Provider professional qualifications.
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supportingInfo | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo Supporting information DefinitionAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Typically these information codes are required to support the services rendered or the adjudication of the services rendered. Often there are multiple jurisdiction specific valuesets which are required.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.sequence Information instance identifier DefinitionA number to uniquely identify supporting information entries. Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.category Classification of the supplied information DefinitionThe general class of the information supplied: information; exception; accident, employment; onset, etc. Required to group or associate information items with common characteristics. For example: admission information or prior treatments. This may contain a category for the local bill type codes. The valuset used for additional information category codes.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.code Type of information DefinitionSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. Required to identify the kind of additional information. This may contain the local bill type codes such as the US UB-04 bill type code. The valuset used for additional information codes.
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timing[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.timing[x] When it occurred DefinitionThe date when or period to which this information refers.
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timingDate | date | There are no (further) constraints on this element Data type | ||
timingPeriod | Period | There are no (further) constraints on this element Data type | ||
value[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.value[x] Data to be provided DefinitionAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. To convey the data content to be provided when the information is more than a simple code or period. 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.
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valueBoolean | boolean | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueReference | Reference(Resource) | There are no (further) constraints on this element Data type | ||
reason | 0..1 | Coding | There are no (further) constraints on this element Element idExplanationOfBenefit.supportingInfo.reason Explanation for the information DefinitionProvides the reason in the situation where a reason code is required in addition to the content. Needed when the supporting information has both a date and amount/value and requires explanation. For example: the reason for the additional stay, or why a tooth is missing. Reason codes for the missing teeth.
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diagnosis | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis Pertinent diagnosis information DefinitionInformation about diagnoses relevant to the claim items. Required for the adjudication by provided context for the services and product listed.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.sequence Diagnosis instance identifier DefinitionA number to uniquely identify diagnosis entries. Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
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diagnosis[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.diagnosis[x] Nature of illness or problem DefinitionThe nature of illness or problem in a coded form or as a reference to an external defined Condition. Provides health context for the evaluation of the products and/or services. ICD10 Diagnostic codes.
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diagnosisCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
diagnosisReference | Reference(Condition) | There are no (further) constraints on this element Data type | ||
type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.type Timing or nature of the diagnosis DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. For example: admitting, primary, secondary, discharge. The type of the diagnosis: admitting, principal, discharge.
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onAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.onAdmission Present on admission DefinitionIndication of whether the diagnosis was present on admission to a facility. Many systems need to understand for adjudication if the diagnosis was present a time of admission. 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. Present on admission.
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packageCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.diagnosis.packageCode Package billing code DefinitionA 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. 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. For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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. The DRG codes associated with the diagnosis.
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procedure | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure Clinical procedures performed DefinitionProcedures performed on the patient relevant to the billing items with the claim. The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.sequence Procedure instance identifier DefinitionA number to uniquely identify procedure entries. Necessary to provide a mechanism to link to claim details. 32 bit number; for values larger than this, use decimal
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type | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.type Category of Procedure DefinitionWhen the condition was observed or the relative ranking. Often required to capture a particular diagnosis, for example: primary or discharge. 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. Example procedure type codes.
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date | 0..1 | dateTime | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.date When the procedure was performed DefinitionDate and optionally time the procedure was performed. Required for auditing purposes.
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procedure[x] | 1..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.procedure[x] Specific clinical procedure DefinitionThe code or reference to a Procedure resource which identifies the clinical intervention performed. This identifies the actual clinical procedure. ICD10 Procedure codes.
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procedureCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
procedureReference | Reference(Procedure) | There are no (further) constraints on this element Data type | ||
udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.procedure.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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precedence | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.precedence Precedence (primary, secondary, etc.) DefinitionThis indicates the relative order of a series of EOBs related to different coverages for the same suite of services. Needed to coordinate between multiple EOBs for the same suite of services. 32 bit number; for values larger than this, use decimal
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insurance | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance Patient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim. At least one insurer is required for a claim to be a claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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focal | Σ | 1..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.focal Coverage to be used for adjudication DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. To identify which coverage in the list is being used to adjudicate this claim. 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.
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coverage | Σ I | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.coverage Insurance information DefinitionReference 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. Required to allow the adjudicator to locate the correct policy and history within their information system. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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preAuthRef | 0..* | string | There are no (further) constraints on this element Element idExplanationOfBenefit.insurance.preAuthRef Prior authorization reference number DefinitionReference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization. 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.
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accident | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.accident Details of the event DefinitionDetails of a accident which resulted in injuries which required the products and services listed in the claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.date When the incident occurred DefinitionDate of an accident event related to the products and services contained in the claim. Required for audit purposes and adjudication. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
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type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.type The nature of the accident DefinitionThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. Coverage may be dependant on the type of accident. 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. Type of accident: work place, auto, etc.
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location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.accident.location[x] Where the event occurred DefinitionThe physical location of the accident event. Required for audit purposes and determination of applicable insurance liability.
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locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
item | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item Product or service provided DefinitionA 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. The items to be processed for adjudication.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.sequence Item instance identifier DefinitionA number to uniquely identify item entries. Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. 32 bit number; for values larger than this, use decimal
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careTeamSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.careTeamSequence Applicable care team members DefinitionCare team members related to this service or product. Need to identify the individuals and their roles in the provision of the product or service. 32 bit number; for values larger than this, use decimal
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diagnosisSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.diagnosisSequence Applicable diagnoses DefinitionDiagnoses applicable for this service or product. Need to related the product or service to the associated diagnoses. 32 bit number; for values larger than this, use decimal
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procedureSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.procedureSequence Applicable procedures DefinitionProcedures applicable for this service or product. Need to provide any listed specific procedures to support the product or service being claimed. 32 bit number; for values larger than this, use decimal
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informationSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.informationSequence Applicable exception and supporting information DefinitionExceptions, special conditions and supporting information applicable for this service or product. Need to reference the supporting information items that relate directly to this product or service. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.modifier Product or service billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.item.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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encounter | I | 0..* | Reference(Encounter) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.encounter Encounters related to this billed item DefinitionA billed item may include goods or services provided in multiple encounters. Used in some jurisdictions to link clinical events to claim items. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication Adjudication details DefinitionIf 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. The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.category Type of adjudication information DefinitionA 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. Needed to enable understanding of the context of the other information in the adjudication. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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reason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.reason Explanation of adjudication outcome DefinitionA code supporting the understanding of the adjudication result and explaining variance from expected amount. To support understanding of variance from adjudication expectations. For example, may indicate that the funds for this benefit type have been exhausted. Adjudication reason codes.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.amount Monetary amount DefinitionMonetary amount associated with the category. Most adjuciation categories convey a monetary amount. For example, amount submitted, eligible amount, co-payment, and benefit payable.
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value | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.adjudication.value Non-monitary value DefinitionA non-monetary value associated with the category. Mutually exclusive to the amount element above. Some adjudication categories convey a percentage or a fixed value. For example: eligible percentage or co-payment percentage.
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detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail Additional items DefinitionSecond-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.adjudication Detail level adjudication details DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail Additional items DefinitionThird-tier of goods and services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.sequence Product or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The items to be processed for adjudication. 32 bit number; for values larger than this, use decimal
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revenue | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.revenue Revenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service. Needed in the processing of institutional claims. 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. Codes for the revenue or cost centers supplying the service and/or products.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. 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. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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udi | I | 0..* | Reference(Device) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.udi Unique device identifier DefinitionUnique Device Identifiers associated with this line item. The UDI code allows the insurer to obtain device level information on the product supplied. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.item.detail.subDetail.adjudication Subdetail level adjudication details DefinitionThe adjudication results. | |
addItem | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem Insurer added line items DefinitionThe first-tier service adjudications for payor added product or service lines. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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itemSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.itemSequence Item sequence number DefinitionClaim items which this service line is intended to replace. Provides references to the claim items. 32 bit number; for values larger than this, use decimal
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detailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detailSequence Detail sequence number DefinitionThe sequence number of the details within the claim item which this line is intended to replace. Provides references to the claim details within the claim item. 32 bit number; for values larger than this, use decimal
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subDetailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subDetailSequence Subdetail sequence number DefinitionThe sequence number of the sub-details woithin the details within the claim item which this line is intended to replace. Provides references to the claim sub-details within the claim detail. 32 bit number; for values larger than this, use decimal
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provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.provider Authorized providers DefinitionThe providers who are authorized for the services rendered to the patient. Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place where the service is rendered.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. 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. The code for the tooth surface and surface combinations.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.adjudication Added items adjudication DefinitionThe adjudication results. | |
detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail Insurer added line items DefinitionThe second-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.adjudication Added items adjudication DefinitionThe adjudication results. | |
subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail Insurer added line items DefinitionThe third-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided. 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.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. 32 bit number; for values larger than this, use decimal
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.addItem.detail.subDetail.adjudication Added items adjudication DefinitionThe adjudication results. | |
adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idExplanationOfBenefit.adjudication Header-level adjudication DefinitionThe adjudication results which are presented at the header level rather than at the line-item or add-item levels. Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | |
total | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.total Adjudication totals DefinitionCategorized monetary totals for the adjudication. To provide the requestor with financial totals by category for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.total.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.total.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.total.category Type of adjudication information DefinitionA 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. Needed to convey the type of total provided. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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amount | Σ | 1..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.total.amount Financial total for the category DefinitionMonetary total amount associated with the category. Needed to convey the total monetary amount.
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payment | 0..1 | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.payment Payment Details DefinitionPayment details for the adjudication of the claim. Needed to convey references to the financial instrument that has been used if payment has been made.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.type Partial or complete payment DefinitionWhether this represents partial or complete payment of the benefits payable. To advise the requestor when the insurer believes all payments to have been completed. 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. The type (partial, complete) of the payment.
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adjustment | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustment Payment adjustment for non-claim issues DefinitionTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. To advise the requestor of adjustments applied to the payment. 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.
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adjustmentReason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.adjustmentReason Explanation for the variance DefinitionReason for the payment adjustment. Needed to clarify the monetary adjustment. 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. Payment Adjustment reason codes.
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date | 0..1 | date | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.date Expected date of payment DefinitionEstimated date the payment will be issued or the actual issue date of payment. To advise the payee when payment can be expected.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.amount Payable amount after adjustment DefinitionBenefits payable less any payment adjustment. Needed to provide the actual payment amount.
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identifier | 0..1 | Identifier | There are no (further) constraints on this element Element idExplanationOfBenefit.payment.identifier Business identifier for the payment DefinitionIssuer's unique identifier for the payment instrument. Enable the receiver to reconcile when payment received. For example: EFT number or check number.
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formCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.formCode Printed form identifier DefinitionA code for the form to be used for printing the content. Needed to specify the specific form used for producing output for this response. May be needed to identify specific jurisdictional forms. The forms codes.
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form | I | 0..1 | Attachment | There are no (further) constraints on this element Element idExplanationOfBenefit.form Printed reference or actual form DefinitionThe actual form, by reference or inclusion, for printing the content or an EOB. Needed to include the specific form used for producing output for this response. Needed to permit insurers to include the actual form.
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processNote | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote Note concerning adjudication DefinitionA note that describes or explains adjudication results in a human readable form. Provides the insurer specific textual explanations associated with the processing.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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number | 0..1 | positiveInt | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.number Note instance identifier DefinitionA number to uniquely identify a note entry. Necessary to provide a mechanism to link from adjudications. 32 bit number; for values larger than this, use decimal
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type | 0..1 | codeBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.type display | print | printoper DefinitionThe business purpose of the note text. To convey the expectation for when the text is used. Note that FHIR strings SHALL NOT exceed 1MB in size The presentation types of notes.
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text | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.text Note explanatory text DefinitionThe explanation or description associated with the processing. Required to provide human readable explanation. Note that FHIR strings SHALL NOT exceed 1MB in size
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language | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idExplanationOfBenefit.processNote.language Language of the text DefinitionA code to define the language used in the text of the note. Note text may vary from the resource defined language. Only required if the language is different from the resource language. A human language.
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benefitPeriod | I | 0..1 | Period | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitPeriod When the benefits are applicable DefinitionThe term of the benefits documented in this response. Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. Not applicable when use=claim.
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benefitBalance | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance Balance by Benefit Category DefinitionBalance by Benefit Category.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. Needed to convey the category of service or product for which eligibility is sought. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision, oral-basic etc.
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excluded | 0..1 | boolean | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.excluded Excluded from the plan DefinitionTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. Needed to identify items that are specifically excluded from the coverage.
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name | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.name Short name for the benefit DefinitionA short name or tag for the benefit. Required to align with other plan names. For example: MED01, or DENT2.
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description | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.description Description of the benefit or services covered DefinitionA richer description of the benefit or services covered. Needed for human readable reference. For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
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network | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.network In or out of network DefinitionIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. Needed as in or out of network providers are treated differently under the coverage. 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. Code to classify in or out of network services.
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unit | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.unit Individual or family DefinitionIndicates if the benefits apply to an individual or to the family. Needed for the understanding of the benefits. 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. Unit covered/serviced - individual or family.
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term | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.term Annual or lifetime DefinitionThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. Needed for the understanding of the benefits. 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. Coverage unit - annual, lifetime.
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financial | 0..* | BackboneElement | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial Benefit Summary DefinitionBenefits Used to date.
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id | 0..1 | string | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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 manageable, 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. 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.
|
type | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.type Benefit classification DefinitionClassification of benefit being provided. Needed to convey the nature of the benefit. For example: deductible, visits, benefit amount. Deductable, visits, co-pay, etc.
| |
allowed[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.allowed[x] Benefits allowed DefinitionThe quantity of the benefit which is permitted under the coverage. Needed to convey the benefits offered under the coverage.
| ||
allowedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
allowedString | string | There are no (further) constraints on this element Data type | ||
allowedMoney | Money | There are no (further) constraints on this element Data type | ||
used[x] | 0..1 | There are no (further) constraints on this element Element idExplanationOfBenefit.benefitBalance.financial.used[x] Benefits used DefinitionThe quantity of the benefit which have been consumed to date. Needed to convey the benefits consumed to date.
| ||
usedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
usedMoney | Money | There are no (further) constraints on this element Data type |
Tabular View of Profile Content
ExplanationOfBenefit | 0..* | |
ExplanationOfBenefit.id | string | 0..1 |
ExplanationOfBenefit.meta | Meta | 0..1 |
ExplanationOfBenefit.implicitRules | uri | 0..1 |
ExplanationOfBenefit.language | code | 0..1 |
ExplanationOfBenefit.text | Narrative | 0..1 |
ExplanationOfBenefit.contained | Resource | 0..* |
ExplanationOfBenefit.extension | Extension | 0..* |
ExplanationOfBenefit.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.identifier | Identifier | 0..* |
ExplanationOfBenefit.status | code | 1..1 |
ExplanationOfBenefit.type | CodeableConcept | 1..1 |
ExplanationOfBenefit.subType | CodeableConcept | 0..1 |
ExplanationOfBenefit.use | code | 1..1 |
ExplanationOfBenefit.patient | Reference(Patient) | 1..1 |
ExplanationOfBenefit.billablePeriod | Period | 0..1 |
ExplanationOfBenefit.created | dateTime | 1..1 |
ExplanationOfBenefit.enterer | Reference(Practitioner | PractitionerRole) | 0..1 |
ExplanationOfBenefit.insurer | Reference(Organization) | 1..1 |
ExplanationOfBenefit.provider | Reference(Practitioner | PractitionerRole | Organization) | 1..1 |
ExplanationOfBenefit.priority | CodeableConcept | 0..1 |
ExplanationOfBenefit.fundsReserveRequested | CodeableConcept | 0..1 |
ExplanationOfBenefit.fundsReserve | CodeableConcept | 0..1 |
ExplanationOfBenefit.related | BackboneElement | 0..* |
ExplanationOfBenefit.related.id | string | 0..1 |
ExplanationOfBenefit.related.extension | Extension | 0..* |
ExplanationOfBenefit.related.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.related.claim | Reference(Claim) | 0..1 |
ExplanationOfBenefit.related.relationship | CodeableConcept | 0..1 |
ExplanationOfBenefit.related.reference | Identifier | 0..1 |
ExplanationOfBenefit.prescription | Reference(MedicationRequest | VisionPrescription) | 0..1 |
ExplanationOfBenefit.originalPrescription | Reference(MedicationRequest) | 0..1 |
ExplanationOfBenefit.payee | BackboneElement | 0..1 |
ExplanationOfBenefit.payee.id | string | 0..1 |
ExplanationOfBenefit.payee.extension | Extension | 0..* |
ExplanationOfBenefit.payee.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.payee.type | CodeableConcept | 0..1 |
ExplanationOfBenefit.payee.party | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | 0..1 |
ExplanationOfBenefit.referral | Reference(ServiceRequest) | 0..1 |
ExplanationOfBenefit.facility | Reference(Location) | 0..1 |
ExplanationOfBenefit.claim | Reference(Claim) | 0..1 |
ExplanationOfBenefit.claimResponse | Reference(ClaimResponse) | 0..1 |
ExplanationOfBenefit.outcome | code | 1..1 |
ExplanationOfBenefit.disposition | string | 0..1 |
ExplanationOfBenefit.preAuthRef | string | 0..* |
ExplanationOfBenefit.preAuthRefPeriod | Period | 0..* |
ExplanationOfBenefit.careTeam | BackboneElement | 0..* |
ExplanationOfBenefit.careTeam.id | string | 0..1 |
ExplanationOfBenefit.careTeam.extension | Extension | 0..* |
ExplanationOfBenefit.careTeam.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.careTeam.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.careTeam.provider | Reference(Practitioner | PractitionerRole | Organization) | 1..1 |
ExplanationOfBenefit.careTeam.responsible | boolean | 0..1 |
ExplanationOfBenefit.careTeam.role | CodeableConcept | 0..1 |
ExplanationOfBenefit.careTeam.qualification | CodeableConcept | 0..1 |
ExplanationOfBenefit.supportingInfo | BackboneElement | 0..* |
ExplanationOfBenefit.supportingInfo.id | string | 0..1 |
ExplanationOfBenefit.supportingInfo.extension | Extension | 0..* |
ExplanationOfBenefit.supportingInfo.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.supportingInfo.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.supportingInfo.category | CodeableConcept | 1..1 |
ExplanationOfBenefit.supportingInfo.code | CodeableConcept | 0..1 |
ExplanationOfBenefit.supportingInfo.timing[x] | date, Period | 0..1 |
ExplanationOfBenefit.supportingInfo.value[x] | boolean, string, Quantity, Attachment, Reference(Resource) | 0..1 |
ExplanationOfBenefit.supportingInfo.reason | Coding | 0..1 |
ExplanationOfBenefit.diagnosis | BackboneElement | 0..* |
ExplanationOfBenefit.diagnosis.id | string | 0..1 |
ExplanationOfBenefit.diagnosis.extension | Extension | 0..* |
ExplanationOfBenefit.diagnosis.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.diagnosis.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.diagnosis.diagnosis[x] | CodeableConcept, Reference(Condition) | 1..1 |
ExplanationOfBenefit.diagnosis.type | CodeableConcept | 0..* |
ExplanationOfBenefit.diagnosis.onAdmission | CodeableConcept | 0..1 |
ExplanationOfBenefit.diagnosis.packageCode | CodeableConcept | 0..1 |
ExplanationOfBenefit.procedure | BackboneElement | 0..* |
ExplanationOfBenefit.procedure.id | string | 0..1 |
ExplanationOfBenefit.procedure.extension | Extension | 0..* |
ExplanationOfBenefit.procedure.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.procedure.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.procedure.type | CodeableConcept | 0..* |
ExplanationOfBenefit.procedure.date | dateTime | 0..1 |
ExplanationOfBenefit.procedure.procedure[x] | CodeableConcept, Reference(Procedure) | 1..1 |
ExplanationOfBenefit.procedure.udi | Reference(Device) | 0..* |
ExplanationOfBenefit.precedence | positiveInt | 0..1 |
ExplanationOfBenefit.insurance | BackboneElement | 1..* |
ExplanationOfBenefit.insurance.id | string | 0..1 |
ExplanationOfBenefit.insurance.extension | Extension | 0..* |
ExplanationOfBenefit.insurance.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.insurance.focal | boolean | 1..1 |
ExplanationOfBenefit.insurance.coverage | Reference(Coverage) | 1..1 |
ExplanationOfBenefit.insurance.preAuthRef | string | 0..* |
ExplanationOfBenefit.accident | BackboneElement | 0..1 |
ExplanationOfBenefit.accident.id | string | 0..1 |
ExplanationOfBenefit.accident.extension | Extension | 0..* |
ExplanationOfBenefit.accident.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.accident.date | date | 0..1 |
ExplanationOfBenefit.accident.type | CodeableConcept | 0..1 |
ExplanationOfBenefit.accident.location[x] | Address, Reference(Location) | 0..1 |
ExplanationOfBenefit.item | BackboneElement | 0..* |
ExplanationOfBenefit.item.id | string | 0..1 |
ExplanationOfBenefit.item.extension | Extension | 0..* |
ExplanationOfBenefit.item.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.item.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.item.careTeamSequence | positiveInt | 0..* |
ExplanationOfBenefit.item.diagnosisSequence | positiveInt | 0..* |
ExplanationOfBenefit.item.procedureSequence | positiveInt | 0..* |
ExplanationOfBenefit.item.informationSequence | positiveInt | 0..* |
ExplanationOfBenefit.item.revenue | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.category | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.item.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.item.programCode | CodeableConcept | 0..* |
ExplanationOfBenefit.item.serviced[x] | date, Period | 0..1 |
ExplanationOfBenefit.item.location[x] | CodeableConcept, Address, Reference(Location) | 0..1 |
ExplanationOfBenefit.item.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.item.unitPrice | Money | 0..1 |
ExplanationOfBenefit.item.factor | decimal | 0..1 |
ExplanationOfBenefit.item.net | Money | 0..1 |
ExplanationOfBenefit.item.udi | Reference(Device) | 0..* |
ExplanationOfBenefit.item.bodySite | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.subSite | CodeableConcept | 0..* |
ExplanationOfBenefit.item.encounter | Reference(Encounter) | 0..* |
ExplanationOfBenefit.item.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.item.adjudication | BackboneElement | 0..* |
ExplanationOfBenefit.item.adjudication.id | string | 0..1 |
ExplanationOfBenefit.item.adjudication.extension | Extension | 0..* |
ExplanationOfBenefit.item.adjudication.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.item.adjudication.category | CodeableConcept | 1..1 |
ExplanationOfBenefit.item.adjudication.reason | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.adjudication.amount | Money | 0..1 |
ExplanationOfBenefit.item.adjudication.value | decimal | 0..1 |
ExplanationOfBenefit.item.detail | BackboneElement | 0..* |
ExplanationOfBenefit.item.detail.id | string | 0..1 |
ExplanationOfBenefit.item.detail.extension | Extension | 0..* |
ExplanationOfBenefit.item.detail.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.item.detail.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.item.detail.revenue | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.detail.category | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.detail.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.item.detail.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.item.detail.programCode | CodeableConcept | 0..* |
ExplanationOfBenefit.item.detail.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.item.detail.unitPrice | Money | 0..1 |
ExplanationOfBenefit.item.detail.factor | decimal | 0..1 |
ExplanationOfBenefit.item.detail.net | Money | 0..1 |
ExplanationOfBenefit.item.detail.udi | Reference(Device) | 0..* |
ExplanationOfBenefit.item.detail.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.item.detail.adjudication | 0..* | |
ExplanationOfBenefit.item.detail.subDetail | BackboneElement | 0..* |
ExplanationOfBenefit.item.detail.subDetail.id | string | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.extension | Extension | 0..* |
ExplanationOfBenefit.item.detail.subDetail.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.item.detail.subDetail.sequence | positiveInt | 1..1 |
ExplanationOfBenefit.item.detail.subDetail.revenue | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.category | CodeableConcept | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.item.detail.subDetail.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.item.detail.subDetail.programCode | CodeableConcept | 0..* |
ExplanationOfBenefit.item.detail.subDetail.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.unitPrice | Money | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.factor | decimal | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.net | Money | 0..1 |
ExplanationOfBenefit.item.detail.subDetail.udi | Reference(Device) | 0..* |
ExplanationOfBenefit.item.detail.subDetail.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.item.detail.subDetail.adjudication | 0..* | |
ExplanationOfBenefit.addItem | BackboneElement | 0..* |
ExplanationOfBenefit.addItem.id | string | 0..1 |
ExplanationOfBenefit.addItem.extension | Extension | 0..* |
ExplanationOfBenefit.addItem.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.addItem.itemSequence | positiveInt | 0..* |
ExplanationOfBenefit.addItem.detailSequence | positiveInt | 0..* |
ExplanationOfBenefit.addItem.subDetailSequence | positiveInt | 0..* |
ExplanationOfBenefit.addItem.provider | Reference(Practitioner | PractitionerRole | Organization) | 0..* |
ExplanationOfBenefit.addItem.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.addItem.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.addItem.programCode | CodeableConcept | 0..* |
ExplanationOfBenefit.addItem.serviced[x] | date, Period | 0..1 |
ExplanationOfBenefit.addItem.location[x] | CodeableConcept, Address, Reference(Location) | 0..1 |
ExplanationOfBenefit.addItem.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.addItem.unitPrice | Money | 0..1 |
ExplanationOfBenefit.addItem.factor | decimal | 0..1 |
ExplanationOfBenefit.addItem.net | Money | 0..1 |
ExplanationOfBenefit.addItem.bodySite | CodeableConcept | 0..1 |
ExplanationOfBenefit.addItem.subSite | CodeableConcept | 0..* |
ExplanationOfBenefit.addItem.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.addItem.adjudication | 0..* | |
ExplanationOfBenefit.addItem.detail | BackboneElement | 0..* |
ExplanationOfBenefit.addItem.detail.id | string | 0..1 |
ExplanationOfBenefit.addItem.detail.extension | Extension | 0..* |
ExplanationOfBenefit.addItem.detail.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.addItem.detail.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.addItem.detail.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.addItem.detail.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.addItem.detail.unitPrice | Money | 0..1 |
ExplanationOfBenefit.addItem.detail.factor | decimal | 0..1 |
ExplanationOfBenefit.addItem.detail.net | Money | 0..1 |
ExplanationOfBenefit.addItem.detail.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.addItem.detail.adjudication | 0..* | |
ExplanationOfBenefit.addItem.detail.subDetail | BackboneElement | 0..* |
ExplanationOfBenefit.addItem.detail.subDetail.id | string | 0..1 |
ExplanationOfBenefit.addItem.detail.subDetail.extension | Extension | 0..* |
ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | CodeableConcept | 1..1 |
ExplanationOfBenefit.addItem.detail.subDetail.modifier | CodeableConcept | 0..* |
ExplanationOfBenefit.addItem.detail.subDetail.quantity | SimpleQuantity | 0..1 |
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice | Money | 0..1 |
ExplanationOfBenefit.addItem.detail.subDetail.factor | decimal | 0..1 |
ExplanationOfBenefit.addItem.detail.subDetail.net | Money | 0..1 |
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber | positiveInt | 0..* |
ExplanationOfBenefit.addItem.detail.subDetail.adjudication | 0..* | |
ExplanationOfBenefit.adjudication | 0..* | |
ExplanationOfBenefit.total | BackboneElement | 0..* |
ExplanationOfBenefit.total.id | string | 0..1 |
ExplanationOfBenefit.total.extension | Extension | 0..* |
ExplanationOfBenefit.total.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.total.category | CodeableConcept | 1..1 |
ExplanationOfBenefit.total.amount | Money | 1..1 |
ExplanationOfBenefit.payment | BackboneElement | 0..1 |
ExplanationOfBenefit.payment.id | string | 0..1 |
ExplanationOfBenefit.payment.extension | Extension | 0..* |
ExplanationOfBenefit.payment.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.payment.type | CodeableConcept | 0..1 |
ExplanationOfBenefit.payment.adjustment | Money | 0..1 |
ExplanationOfBenefit.payment.adjustmentReason | CodeableConcept | 0..1 |
ExplanationOfBenefit.payment.date | date | 0..1 |
ExplanationOfBenefit.payment.amount | Money | 0..1 |
ExplanationOfBenefit.payment.identifier | Identifier | 0..1 |
ExplanationOfBenefit.formCode | CodeableConcept | 0..1 |
ExplanationOfBenefit.form | Attachment | 0..1 |
ExplanationOfBenefit.processNote | BackboneElement | 0..* |
ExplanationOfBenefit.processNote.id | string | 0..1 |
ExplanationOfBenefit.processNote.extension | Extension | 0..* |
ExplanationOfBenefit.processNote.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.processNote.number | positiveInt | 0..1 |
ExplanationOfBenefit.processNote.type | code | 0..1 |
ExplanationOfBenefit.processNote.text | string | 0..1 |
ExplanationOfBenefit.processNote.language | CodeableConcept | 0..1 |
ExplanationOfBenefit.benefitPeriod | Period | 0..1 |
ExplanationOfBenefit.benefitBalance | BackboneElement | 0..* |
ExplanationOfBenefit.benefitBalance.id | string | 0..1 |
ExplanationOfBenefit.benefitBalance.extension | Extension | 0..* |
ExplanationOfBenefit.benefitBalance.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.benefitBalance.category | CodeableConcept | 1..1 |
ExplanationOfBenefit.benefitBalance.excluded | boolean | 0..1 |
ExplanationOfBenefit.benefitBalance.name | string | 0..1 |
ExplanationOfBenefit.benefitBalance.description | string | 0..1 |
ExplanationOfBenefit.benefitBalance.network | CodeableConcept | 0..1 |
ExplanationOfBenefit.benefitBalance.unit | CodeableConcept | 0..1 |
ExplanationOfBenefit.benefitBalance.term | CodeableConcept | 0..1 |
ExplanationOfBenefit.benefitBalance.financial | BackboneElement | 0..* |
ExplanationOfBenefit.benefitBalance.financial.id | string | 0..1 |
ExplanationOfBenefit.benefitBalance.financial.extension | Extension | 0..* |
ExplanationOfBenefit.benefitBalance.financial.modifierExtension | Extension | 0..* |
ExplanationOfBenefit.benefitBalance.financial.type | CodeableConcept | 1..1 |
ExplanationOfBenefit.benefitBalance.financial.allowed[x] | unsignedInt, string, Money | 0..1 |
ExplanationOfBenefit.benefitBalance.financial.used[x] | unsignedInt, Money | 0..1 |