My Health Record FHIR IG
1.3.0 - active
My Health Record FHIR IG
1.3.0 - active
My Health Record FHIR IG - Local Development build (v1.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-explanationofbenefit-medicare-mbs-1 | Version: 1.3.0 | |||
| Active as of 2024-10-25 | Computable Name: ADHAExplanationofBenefitMBS | |||
Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/. |
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The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS) or Department of Veterans' Affairs (DVA) for the electronic exchange of digital health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.
This profile identifies the additional constraints, extensions, and value sets that build on and extend ExplanationOfBenefit that are supported.
This profile is designed to set an ExplanationOfBenefit standard for:
None.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |
  identifier |
S | 1..* | Identifier | Business Identifier for the resource |
| status |
S | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active |
| type |
S | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category  (required) |
| use |
S | 1..1 | code | claim | preauthorization | predetermination Fixed Value: claim |
 patient |
SC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present |
| created |
SC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day |
| insurer |
SC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present |
| provider |
S | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |
| outcome |
S | 1..1 | code | queued | complete | error | partial Fixed Value: complete |
 insurance |
S | 1..1 | BackboneElement | Patient insurance information |
 focal |
S | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
 coverage |
S | 1..1 | Reference(Coverage) | Medicare or Veteran card information |
 item |
S | 1..1 | BackboneElement | Product or service provided |
 sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) |
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Required Pattern: At least the following |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |
| serviced[x] |
S | 1..1 | date, Period | Date or dates of service or product delivery |
 location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
S | 1..* | Identifier | Business Identifier for the resource |
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active |
| type |
SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) |
| use |
SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim |
| patient |
SΣC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present |
| created |
SΣC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day |
| insurer |
SΣC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present |
| provider |
SΣ | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete |
| insurance |
SΣ | 1..1 | BackboneElement | Patient insurance information |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal |
SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
| coverage |
SΣ | 1..1 | Reference(Coverage) | Medicare or Veteran card information |
| item |
S | 1..1 | BackboneElement | Product or service provided |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) |
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |
 serviced[x] |
S | 1..1 | Date or dates of service or product delivery | |
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ExplanationOfBenefit.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.use | required | Fixed Value: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| ExplanationOfBenefit.outcome | required | Fixed Value: completehttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.item.productOrService | example | Pattern: nullhttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ExplanationOfBenefit.item.location[x] | example | Pattern: HOSPhttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
S | 1..* | Identifier | Business Identifier for the resource | ||||
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
| type |
SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) | ||||
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) | ||||
| use |
SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim | ||||
| patient |
SΣC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present | ||||
| billablePeriod |
Σ | 0..1 | Period | Relevant time frame for the claim | ||||
| created |
SΣC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day | ||||
| enterer |
0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
| insurer |
SΣC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present | ||||
| provider |
SΣ | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim | ||||
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |||||
| fundsReserveRequested |
0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related |
0..* | BackboneElement | Prior or corollary claims | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim |
0..1 | Reference(Claim) | Reference to the related claim | |||||
| relationship |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| reference |
0..1 | Identifier | File or case reference | |||||
| prescription |
0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
| originalPrescription |
0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
| payee |
0..1 | BackboneElement | Recipient of benefits payable | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party |
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
| referral |
0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
| facility |
0..1 | Reference(Location) | Servicing Facility | |||||
| claim |
0..1 | Reference(Claim) | Claim reference | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Claim response reference | |||||
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..* | string | Preauthorization reference | |||||
| preAuthRefPeriod |
0..* | Period | Preauthorization in-effect period | |||||
| careTeam |
0..* | BackboneElement | Care Team members | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
| responsible |
0..1 | boolean | Indicator of the lead practitioner | |||||
| role |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
| qualification |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo |
0..* | BackboneElement | Supporting information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Information instance identifier | |||||
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
| code |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
| timing[x] |
0..1 | When it occurred | ||||||
| timingDate |
date | |||||||
| timingPeriod |
Period | |||||||
| value[x] |
0..1 | Data to be provided | ||||||
| valueBoolean |
boolean | |||||||
| valueString |
string | |||||||
| valueQuantity |
Quantity | |||||||
| valueAttachment |
Attachment | |||||||
| valueReference |
Reference(Resource) | |||||||
| reason |
0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |||||
| diagnosis[x] |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept |
CodeableConcept | |||||||
| diagnosisReference |
Reference(Condition) | |||||||
| type |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Procedure instance identifier | |||||
| type |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date |
0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
| procedureCodeableConcept |
CodeableConcept | |||||||
| procedureReference |
Reference(Procedure) | |||||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| precedence |
0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
| insurance |
SΣ | 1..1 | BackboneElement | Patient insurance information | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| focal |
SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true | ||||
| coverage |
SΣ | 1..1 | Reference(Coverage) | Medicare or Veteran card information | ||||
| preAuthRef |
0..* | string | Prior authorization reference number | |||||
| accident |
0..1 | BackboneElement | Details of the event | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date |
0..1 | date | When the incident occurred | |||||
| type |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| location[x] |
0..1 | Where the event occurred | ||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| item |
S | 1..1 | BackboneElement | Product or service provided | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 | ||||
| careTeamSequence |
0..* | positiveInt | Applicable care team members | |||||
| diagnosisSequence |
0..* | positiveInt | Applicable diagnoses | |||||
| procedureSequence |
0..* | positiveInt | Applicable procedures | |||||
| informationSequence |
0..* | positiveInt | Applicable exception and supporting information | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) | ||||
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
0..1 | code | Symbol in syntax defined by the system | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| modifier |
0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
S | 1..1 | Date or dates of service or product delivery | |||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services | ||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monitary value | |||||
| detail |
0..* | BackboneElement | Additional items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Product or service provided | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Additional items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Product or service provided | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
| addItem |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..* | positiveInt | Item sequence number | |||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subDetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| provider |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| detail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
0..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text |
0..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| benefitPeriod |
0..1 | Period | When the benefits are applicable | |||||
| benefitBalance |
0..* | BackboneElement | Balance by Benefit Category | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| excluded |
0..1 | boolean | Excluded from the plan | |||||
| name |
0..1 | string | Short name for the benefit | |||||
| description |
0..1 | string | Description of the benefit or services covered | |||||
| network |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
| unit |
0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
| term |
0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
| financial |
0..* | BackboneElement | Benefit Summary | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
| allowed[x] |
0..1 | Benefits allowed | ||||||
| allowedUnsignedInt |
unsignedInt | |||||||
| allowedString |
string | |||||||
| allowedMoney |
Money | |||||||
| used[x] |
0..1 | Benefits used | ||||||
| usedUnsignedInt |
unsignedInt | |||||||
| usedMoney |
Money | |||||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ExplanationOfBenefit.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ExplanationOfBenefit.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | ||||
| ExplanationOfBenefit.use | required | Fixed Value: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | ||||
| ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationshipfrom the FHIR Standard | ||||
| ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.outcome | required | Fixed Value: completehttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrolefrom the FHIR Standard | ||||
| ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualificationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exceptionfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10from the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admissionfrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroupfrom the FHIR Standard | ||||
| ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-typefrom the FHIR Standard | ||||
| ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-proceduresfrom the FHIR Standard | ||||
| ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
| ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | ||||
| ExplanationOfBenefit.item.productOrService | example | Pattern: nullhttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.location[x] | example | Pattern: HOSPhttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-networkfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unitfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-termfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-typefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 5 elements
Must-Support: 20 elements
Fixed: 5 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from ExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |
| identifier |
S | 1..* | Identifier | Business Identifier for the resource |
| status |
S | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active |
| type |
S | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) |
| use |
S | 1..1 | code | claim | preauthorization | predetermination Fixed Value: claim |
| patient |
SC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present |
| created |
SC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day |
| insurer |
SC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present |
| provider |
S | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |
| outcome |
S | 1..1 | code | queued | complete | error | partial Fixed Value: complete |
| insurance |
S | 1..1 | BackboneElement | Patient insurance information |
| focal |
S | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
| coverage |
S | 1..1 | Reference(Coverage) | Medicare or Veteran card information |
| item |
S | 1..1 | BackboneElement | Product or service provided |
| sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) |
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |
| serviced[x] |
S | 1..1 | date, Period | Date or dates of service or product delivery |
| location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
S | 1..* | Identifier | Business Identifier for the resource |
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active |
| type |
SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) |
| use |
SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim |
| patient |
SΣC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present |
| created |
SΣC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day |
| insurer |
SΣC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present |
| provider |
SΣ | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete |
| insurance |
SΣ | 1..1 | BackboneElement | Patient insurance information |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal |
SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
| coverage |
SΣ | 1..1 | Reference(Coverage) | Medicare or Veteran card information |
| item |
S | 1..1 | BackboneElement | Product or service provided |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) |
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |
| serviced[x] |
S | 1..1 | Date or dates of service or product delivery | |
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ExplanationOfBenefit.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.use | required | Fixed Value: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| ExplanationOfBenefit.outcome | required | Fixed Value: completehttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | |
| ExplanationOfBenefit.item.productOrService | example | Pattern: nullhttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ExplanationOfBenefit.item.location[x] | example | Pattern: HOSPhttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ExplanationOfBenefit |
0..* | ExplanationOfBenefit | Record of Claim against MBS or DVA | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
S | 1..* | Identifier | Business Identifier for the resource | ||||
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
| type |
SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) | ||||
| subType |
S | 1..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) | ||||
| use |
SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim | ||||
| patient |
SΣC | 1..1 | Reference(ADHA Core Patient) | The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present | ||||
| billablePeriod |
Σ | 0..1 | Period | Relevant time frame for the claim | ||||
| created |
SΣC | 1..1 | dateTime | Response creation date inv-dh-eob-03: Date shall be at least to day | ||||
| enterer |
0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
| insurer |
SΣC | 1..1 | Reference(ADHA Core Organization) | Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present | ||||
| provider |
SΣ | 1..1 | Reference(ADHA Core PractitionerRole) | Party responsible for the claim | ||||
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example) | |||||
| fundsReserveRequested |
0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related |
0..* | BackboneElement | Prior or corollary claims | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim |
0..1 | Reference(Claim) | Reference to the related claim | |||||
| relationship |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| reference |
0..1 | Identifier | File or case reference | |||||
| prescription |
0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
| originalPrescription |
0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
| payee |
0..1 | BackboneElement | Recipient of benefits payable | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party |
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
| referral |
0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
| facility |
0..1 | Reference(Location) | Servicing Facility | |||||
| claim |
0..1 | Reference(Claim) | Claim reference | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Claim response reference | |||||
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..* | string | Preauthorization reference | |||||
| preAuthRefPeriod |
0..* | Period | Preauthorization in-effect period | |||||
| careTeam |
0..* | BackboneElement | Care Team members | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
| responsible |
0..1 | boolean | Indicator of the lead practitioner | |||||
| role |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
| qualification |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo |
0..* | BackboneElement | Supporting information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Information instance identifier | |||||
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
| code |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
| timing[x] |
0..1 | When it occurred | ||||||
| timingDate |
date | |||||||
| timingPeriod |
Period | |||||||
| value[x] |
0..1 | Data to be provided | ||||||
| valueBoolean |
boolean | |||||||
| valueString |
string | |||||||
| valueQuantity |
Quantity | |||||||
| valueAttachment |
Attachment | |||||||
| valueReference |
Reference(Resource) | |||||||
| reason |
0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |||||
| diagnosis[x] |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept |
CodeableConcept | |||||||
| diagnosisReference |
Reference(Condition) | |||||||
| type |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Procedure instance identifier | |||||
| type |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date |
0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
| procedureCodeableConcept |
CodeableConcept | |||||||
| procedureReference |
Reference(Procedure) | |||||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| precedence |
0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
| insurance |
SΣ | 1..1 | BackboneElement | Patient insurance information | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| focal |
SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true | ||||
| coverage |
SΣ | 1..1 | Reference(Coverage) | Medicare or Veteran card information | ||||
| preAuthRef |
0..* | string | Prior authorization reference number | |||||
| accident |
0..1 | BackboneElement | Details of the event | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date |
0..1 | date | When the incident occurred | |||||
| type |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| location[x] |
0..1 | Where the event occurred | ||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| item |
S | 1..1 | BackboneElement | Product or service provided | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 | ||||
| careTeamSequence |
0..* | positiveInt | Applicable care team members | |||||
| diagnosisSequence |
0..* | positiveInt | Applicable diagnoses | |||||
| procedureSequence |
0..* | positiveInt | Applicable procedures | |||||
| informationSequence |
0..* | positiveInt | Applicable exception and supporting information | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
S | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) | ||||
| productOrService |
S | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
0..1 | code | Symbol in syntax defined by the system | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| modifier |
0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
S | 1..1 | Date or dates of service or product delivery | |||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
S | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| quantity |
S | 0..1 | SimpleQuantity | Count of products or services | ||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monitary value | |||||
| detail |
0..* | BackboneElement | Additional items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Product or service provided | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Additional items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Product or service provided | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
| addItem |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..* | positiveInt | Item sequence number | |||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subDetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| provider |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| detail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
| adjudication |
0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
0..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text |
0..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| benefitPeriod |
0..1 | Period | When the benefits are applicable | |||||
| benefitBalance |
0..* | BackboneElement | Balance by Benefit Category | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
| excluded |
0..1 | boolean | Excluded from the plan | |||||
| name |
0..1 | string | Short name for the benefit | |||||
| description |
0..1 | string | Description of the benefit or services covered | |||||
| network |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
| unit |
0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
| term |
0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
| financial |
0..* | BackboneElement | Benefit Summary | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
| allowed[x] |
0..1 | Benefits allowed | ||||||
| allowedUnsignedInt |
unsignedInt | |||||||
| allowedString |
string | |||||||
| allowedMoney |
Money | |||||||
| used[x] |
0..1 | Benefits used | ||||||
| usedUnsignedInt |
unsignedInt | |||||||
| usedMoney |
Money | |||||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ExplanationOfBenefit.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ExplanationOfBenefit.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ExplanationOfBenefit.subType | required | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | ||||
| ExplanationOfBenefit.use | required | Fixed Value: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | ||||
| ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationshipfrom the FHIR Standard | ||||
| ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.outcome | required | Fixed Value: completehttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrolefrom the FHIR Standard | ||||
| ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualificationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exceptionfrom the FHIR Standard | ||||
| ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10from the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admissionfrom the FHIR Standard | ||||
| ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroupfrom the FHIR Standard | ||||
| ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-typefrom the FHIR Standard | ||||
| ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-proceduresfrom the FHIR Standard | ||||
| ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
| ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.category | extensible | AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 | ||||
| ExplanationOfBenefit.item.productOrService | example | Pattern: nullhttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.location[x] | example | Pattern: HOSPhttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ExplanationOfBenefit.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-networkfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unitfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-termfrom the FHIR Standard | ||||
| ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-typefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| inv-dh-eob-01 | error | ExplanationOfBenefit.patient | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-02 | error | ExplanationOfBenefit.insurer | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() | |
| inv-dh-eob-03 | error | ExplanationOfBenefit.created | Date shall be at least to day : toString().length() >= 10 |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 5 elements
Must-Support: 20 elements
Fixed: 5 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ Australian Digital Health Agency. Package au.digitalhealth.r4#1.3.0 based on FHIR 4.0.1. Generated 2024-10-25
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