My Health Record FHIR IG
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My Health Record FHIR IG - Local Development build (v1.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: ADHAExplanationofBenefitPBS - Detailed Descriptions

Active as of 2024-09-19

Definitions for the dh-explanationofbenefit-medicare-pbs-1 resource profile.

Guidance on how to interpret the contents of this table can be found here

0. ExplanationOfBenefit
Definition

A record of the claim of an item claimed against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS). Claim items include information about pharmaceutical items prescribed and dispensed to an individual that were partially or fully funded under the PBS or RPBS.

ShortRecord of Claim against PBS or RPBS
2. ExplanationOfBenefit.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..?
Must Supporttrue
4. ExplanationOfBenefit.status
Must Supporttrue
Fixed Valueactive
6. ExplanationOfBenefit.type
Must Supporttrue
Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
    "code" : "pharmacy"
  }]
}
8. ExplanationOfBenefit.subType
Control1..?
BindingThe codes SHALL be taken from Australian Medicare Benefit and Claim Category .
(required to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
Must Supporttrue
10. ExplanationOfBenefit.use
Must Supporttrue
Fixed Valueclaim
12. ExplanationOfBenefit.patient
TypeReference(ADHA Core Patient)
Must Supporttrue
Invariantsinv-dh-eob-01: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
14. ExplanationOfBenefit.created
Must Supporttrue
Invariantsinv-dh-eob-03: Date shall be at least to day (toString().length() >= 10)
16. ExplanationOfBenefit.insurer
ShortAustralian Government department that subsidises the benefits scheme
Comments

In the context of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS), the insurer is the Australian Government Department of Health.

TypeReference(ADHA Core Organization)
Must Supporttrue
Invariantsinv-dh-eob-02: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
18. ExplanationOfBenefit.provider
TypeReference(ADHA Core PractitionerRole)
Must Supporttrue
20. ExplanationOfBenefit.priority
BindingFor example codes, see ProcessPriorityCodes
(example to http://hl7.org/fhir/ValueSet/process-priority)
22. ExplanationOfBenefit.prescription
Control1..?
TypeReference(ADHA PBS Claim Item)
Must Supporttrue
24. ExplanationOfBenefit.prescription.reference
Control1..?
26. ExplanationOfBenefit.outcome
Must Supporttrue
Fixed Valuecomplete
28. ExplanationOfBenefit.insurance
Control0..1
Must Supporttrue
30. ExplanationOfBenefit.insurance.focal
Must Supporttrue
Fixed Valuetrue
32. ExplanationOfBenefit.insurance.coverage
ShortMedicare or Veteran card information
Comments

Medicare or veteran card information may not be available in some records, for example if this resource describes claim information that was originally in another format.

Must Supporttrue
34. ExplanationOfBenefit.item
Control1..1
Must Supporttrue
36. ExplanationOfBenefit.item.sequence
Must Supporttrue
Fixed Value1
38. ExplanationOfBenefit.item.category
Control1..?
BindingUnless not suitable, these codes SHALL be taken from Australian Medicare Benefit and Claim Category .
(extensible to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
Must Supporttrue
40. ExplanationOfBenefit.item.productOrService
Definition

The billing code the service was claimed with against the Australian Department of Health Modified PBS Schedule Item.

ShortPBS Billing code
Comments

The code as instantiated may be padded with leading zeros when compared with the original (as published by the Department of Health).

BindingUnless not suitable, these codes SHALL be taken from PBS Item Codes
(extensible to http://terminology.hl7.org.au/ValueSet/pbs-item)
Must Supporttrue
42. ExplanationOfBenefit.item.serviced[x]
Control1..?
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Must Supporttrue
44. ExplanationOfBenefit.item.quantity
Must Supporttrue

Guidance on how to interpret the contents of this table can be found here

0. ExplanationOfBenefit
Definition

A record of the claim of an item claimed against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS). Claim items include information about pharmaceutical items prescribed and dispensed to an individual that were partially or fully funded under the PBS or RPBS.


This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

ShortRecord of Claim against PBS or RPBSExplanation of Benefit resource
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesEOB
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ExplanationOfBenefit.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. ExplanationOfBenefit.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. ExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

ShortBusiness Identifier for the resource
NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows EOBs to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ExplanationOfBenefit.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Fixed Valueactive
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ExplanationOfBenefit.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

ShortCategory or discipline
Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
    "code" : "pharmacy"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ExplanationOfBenefit.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Control10..1
BindingThe codes SHALL be taken from For example codes, see Australian Medicare Benefit and Claim Category .http://hl7.org/fhir/ValueSet/claim-subtype
(required to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Complete, proposed, exploratory, other.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

This element is required to understand the nature of the request for adjudication.

Fixed Valueclaim
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

ShortThe recipient of the products and services
Control1..1
This element is affected by the following invariants: inv-dh-eob-01
TypeReference(ADHA Core Patient, Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-01: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
18. ExplanationOfBenefit.created
Definition

The date this resource was created.

ShortResponse creation date
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Control1..1
This element is affected by the following invariants: inv-dh-eob-03
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-03: Date shall be at least to day (toString().length() >= 10)
20. ExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortAustralian Government department that subsidises the benefits schemeParty responsible for reimbursement
Comments

In the context of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS), the insurer is the Australian Government Department of Health.

Control1..1
This element is affected by the following invariants: inv-dh-eob-02
TypeReference(ADHA Core Organization, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-02: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
22. ExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

ShortParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control1..1
TypeReference(ADHA Core PractitionerRole, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ExplanationOfBenefit.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

ShortDesired processing urgency
Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

Control0..1
BindingFor example codes, see ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority
(example to http://hl7.org/fhir/ValueSet/process-priority)
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ExplanationOfBenefit.prescription
Definition

Prescription to support the dispensing of pharmacy, device or vision products.

ShortPrescription authorizing services or products
Control10..1
TypeReference(ADHA PBS Claim Item, MedicationRequest, VisionPrescription)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required to authorize the dispensing of controlled substances and devices.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ExplanationOfBenefit.prescription.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ExplanationOfBenefit.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Shortqueued | complete | error | partial
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

The result of the claim processing.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Fixed Valuecomplete
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ExplanationOfBenefit.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

ShortPatient insurance information
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Control1..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

At least one insurer is required for a claim to be a claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ExplanationOfBenefit.insurance.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
36. ExplanationOfBenefit.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

ShortCoverage to be used for adjudication
Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Control1..1
Typeboolean
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Fixed Valuetrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ExplanationOfBenefit.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

ShortMedicare or Veteran card informationInsurance information
Comments

Medicare or veteran card information may not be available in some records, for example if this resource describes claim information that was originally in another format.

Control1..1
TypeReference(Coverage)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ExplanationOfBenefit.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

ShortProduct or service provided
Control10..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The items to be processed for adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. ExplanationOfBenefit.item.sequence
Definition

A number to uniquely identify item entries.

ShortItem instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Fixed Value1
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

ShortBenefit classification
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Control10..1
BindingUnless not suitable, these codes SHALL be taken from For example codes, see Australian Medicare Benefit and Claim Category .http://hl7.org/fhir/ValueSet/ex-benefitcategory
(extensible to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ExplanationOfBenefit.item.productOrService
Definition

The billing code the service was claimed with against the Australian Department of Health Modified PBS Schedule Item.


When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortPBS Billing codeBilling, service, product, or drug code
Comments

The code as instantiated may be padded with leading zeros when compared with the original (as published by the Department of Health).


If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from For example codes, see PBS Item Codeshttp://hl7.org/fhir/ValueSet/service-uscls
(extensible to http://terminology.hl7.org.au/ValueSet/pbs-item)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code, Bill Code, Service Code
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. ExplanationOfBenefit.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

ShortDate or dates of service or product delivery
Control10..1
TypeChoice of: date, Period
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. ExplanationOfBenefit.item.quantity
Definition

The number of repetitions of a service or product.

ShortCount of products or services
Control0..1
TypeQuantity(SimpleQuantity)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. ExplanationOfBenefit
Definition

A record of the claim of an item claimed against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS). Claim items include information about pharmaceutical items prescribed and dispensed to an individual that were partially or fully funded under the PBS or RPBS.

ShortRecord of Claim against PBS or RPBS
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesEOB
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ExplanationOfBenefit.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. ExplanationOfBenefit.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. ExplanationOfBenefit.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ExplanationOfBenefit.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ExplanationOfBenefit.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ExplanationOfBenefit.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. ExplanationOfBenefit.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. ExplanationOfBenefit.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. ExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

ShortBusiness Identifier for the resource
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows EOBs to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ExplanationOfBenefit.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from ExplanationOfBenefitStatus
(required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Fixed Valueactive
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ExplanationOfBenefit.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

ShortCategory or discipline
Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
    "code" : "pharmacy"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ExplanationOfBenefit.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Control1..1
BindingThe codes SHALL be taken from Australian Medicare Benefit and Claim Category .
(required to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Use
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Complete, proposed, exploratory, other.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

This element is required to understand the nature of the request for adjudication.

Fixed Valueclaim
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

ShortThe recipient of the products and services
Control1..1
This element is affected by the following invariants: inv-dh-eob-01
TypeReference(ADHA Core Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-01: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
30. ExplanationOfBenefit.billablePeriod
Definition

The period for which charges are being submitted.

ShortRelevant time frame for the claim
Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ExplanationOfBenefit.created
Definition

The date this resource was created.

ShortResponse creation date
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Control1..1
This element is affected by the following invariants: inv-dh-eob-03
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-03: Date shall be at least to day (toString().length() >= 10)
34. ExplanationOfBenefit.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

ShortAuthor of the claim
Control0..1
TypeReference(Practitioner, PractitionerRole)
Is Modifierfalse
Summaryfalse
Requirements

Some jurisdictions require the contact information for personnel completing claims.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. ExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortAustralian Government department that subsidises the benefits scheme
Comments

In the context of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS), the insurer is the Australian Government Department of Health.

Control1..1
This element is affected by the following invariants: inv-dh-eob-02
TypeReference(ADHA Core Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
inv-dh-eob-02: At least reference or a valid identifier shall be present (reference.exists() or identifier.where(system.count() + value.count() >1).exists())
38. ExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

ShortParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control1..1
TypeReference(ADHA Core PractitionerRole)
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ExplanationOfBenefit.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

ShortDesired processing urgency
Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

Control0..1
BindingFor example codes, see ProcessPriorityCodes
(example to http://hl7.org/fhir/ValueSet/process-priority)
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.fundsReserveRequested
Definition

A code to indicate whether and for whom funds are to be reserved for future claims.

ShortFor whom to reserve funds
Comments

This field is only used for preauthorizations.

Control0..1
BindingFor example codes, see Funds Reservation Codes
(example to http://hl7.org/fhir/ValueSet/fundsreserve)

For whom funds are to be reserved: (Patient, Provider, None).

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Alternate NamesFund pre-allocation
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. ExplanationOfBenefit.fundsReserve
Definition

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

ShortFunds reserved status
Comments

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Control0..1
BindingFor example codes, see Funds Reservation Codes
(example to http://hl7.org/fhir/ValueSet/fundsreserve)

For whom funds are to be reserved: (Patient, Provider, None).

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

ShortPrior or corollary claims
Comments

For example, for the original treatment and follow-up exams.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ExplanationOfBenefit.related.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
50. ExplanationOfBenefit.related.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. ExplanationOfBenefit.related.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
54. ExplanationOfBenefit.related.claim
Definition

Reference to a related claim.

ShortReference to the related claim
Control0..1
TypeReference(Claim)
Is Modifierfalse
Summaryfalse
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. ExplanationOfBenefit.related.relationship
Definition

A code to convey how the claims are related.

ShortHow the reference claim is related
Comments

For example, prior claim or umbrella.

Control0..1
BindingFor example codes, see ExampleRelatedClaimRelationshipCodes
(example to http://hl7.org/fhir/ValueSet/related-claim-relationship)

Relationship of this claim to a related Claim.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Some insurers need a declaration of the type of relationship.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. ExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

ShortFile or case reference
Comments

For example, Property/Casualty insurer claim number or Workers Compensation case number.

Control0..1
TypeIdentifier
Is Modifierfalse
Summaryfalse
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. ExplanationOfBenefit.prescription
Definition

Prescription to support the dispensing of pharmacy, device or vision products.

ShortPrescription authorizing services or products
Control1..1
TypeReference(ADHA PBS Claim Item)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required to authorize the dispensing of controlled substances and devices.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. ExplanationOfBenefit.prescription.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
64. ExplanationOfBenefit.prescription.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ExplanationOfBenefit.prescription.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 66. ExplanationOfBenefit.prescription.reference
    Definition

    A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

    ShortLiteral reference, Relative, internal or absolute URL
    Comments

    Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

    Control1..1
    This element is affected by the following invariants: ref-1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    68. ExplanationOfBenefit.prescription.type
    Definition

    The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

    The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

    ShortType the reference refers to (e.g. "Patient")
    Comments

    This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from ResourceType
    (extensible to http://hl7.org/fhir/ValueSet/resource-types)

    Aa resource (or, for logical models, the URI of the logical model).

    Typeuri
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    70. ExplanationOfBenefit.prescription.identifier
    Definition

    An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

    ShortLogical reference, when literal reference is not known
    Comments

    When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

    When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

    Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

    Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..1
    TypeIdentifier
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    72. ExplanationOfBenefit.prescription.display
    Definition

    Plain text narrative that identifies the resource in addition to the resource reference.

    ShortText alternative for the resource
    Comments

    This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    74. ExplanationOfBenefit.originalPrescription
    Definition

    Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

    ShortOriginal prescription if superceded by fulfiller
    Comments

    For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

    Control0..1
    TypeReference(MedicationRequest)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    76. ExplanationOfBenefit.payee
    Definition

    The party to be reimbursed for cost of the products and services according to the terms of the policy.

    ShortRecipient of benefits payable
    Comments

    Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

    Control0..1
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    78. ExplanationOfBenefit.payee.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    80. ExplanationOfBenefit.payee.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    82. ExplanationOfBenefit.payee.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    84. ExplanationOfBenefit.payee.type
    Definition

    Type of Party to be reimbursed: Subscriber, provider, other.

    ShortCategory of recipient
    Control0..1
    BindingFor example codes, see Claim Payee Type Codes
    (example to http://hl7.org/fhir/ValueSet/payeetype)

    A code for the party to be reimbursed.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    86. ExplanationOfBenefit.payee.party
    Definition

    Reference to the individual or organization to whom any payment will be made.

    ShortRecipient reference
    Comments

    Not required if the payee is 'subscriber' or 'provider'.

    Control0..1
    TypeReference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    88. ExplanationOfBenefit.referral
    Definition

    A reference to a referral resource.

    ShortTreatment Referral
    Comments

    The referral resource which lists the date, practitioner, reason and other supporting information.

    Control0..1
    TypeReference(ServiceRequest)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Some insurers require proof of referral to pay for services or to pay specialist rates for services.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    90. ExplanationOfBenefit.facility
    Definition

    Facility where the services were provided.

    ShortServicing Facility
    Control0..1
    TypeReference(Location)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Insurance adjudication can be dependant on where services were delivered.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    92. ExplanationOfBenefit.claim
    Definition

    The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

    ShortClaim reference
    Control0..1
    TypeReference(Claim)
    Is Modifierfalse
    Summaryfalse
    Requirements

    To provide a link to the original adjudication request.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    94. ExplanationOfBenefit.claimResponse
    Definition

    The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

    ShortClaim response reference
    Control0..1
    TypeReference(ClaimResponse)
    Is Modifierfalse
    Summaryfalse
    Requirements

    To provide a link to the original adjudication response.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    96. ExplanationOfBenefit.outcome
    Definition

    The outcome of the claim, predetermination, or preauthorization processing.

    Shortqueued | complete | error | partial
    Comments

    The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

    Control1..1
    BindingThe codes SHALL be taken from ClaimProcessingCodes
    (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

    The result of the claim processing.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    To advise the requestor of an overall processing outcome.

    Fixed Valuecomplete
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    98. ExplanationOfBenefit.disposition
    Definition

    A human readable description of the status of the adjudication.

    ShortDisposition Message
    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provided for user display.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    100. ExplanationOfBenefit.preAuthRef
    Definition

    Reference from the Insurer which is used in later communications which refers to this adjudication.

    ShortPreauthorization reference
    Comments

    This value is only present on preauthorization adjudications.

    Control0..*
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    On subsequent claims, the insurer may require the provider to quote this value.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    102. ExplanationOfBenefit.preAuthRefPeriod
    Definition

    The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

    ShortPreauthorization in-effect period
    Comments

    This value is only present on preauthorization adjudications.

    Control0..*
    TypePeriod
    Is Modifierfalse
    Summaryfalse
    Requirements

    On subsequent claims, the insurer may require the provider to quote this value.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    104. ExplanationOfBenefit.careTeam
    Definition

    The members of the team who provided the products and services.

    ShortCare Team members
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Common to identify the responsible and supporting practitioners.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    106. ExplanationOfBenefit.careTeam.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    108. ExplanationOfBenefit.careTeam.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    110. ExplanationOfBenefit.careTeam.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    112. ExplanationOfBenefit.careTeam.sequence
    Definition

    A number to uniquely identify care team entries.

    ShortOrder of care team
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    114. ExplanationOfBenefit.careTeam.provider
    Definition

    Member of the team who provided the product or service.

    ShortPractitioner or organization
    Control1..1
    TypeReference(Practitioner, PractitionerRole, Organization)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Often a regulatory requirement to specify the responsible provider.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    116. ExplanationOfBenefit.careTeam.responsible
    Definition

    The party who is billing and/or responsible for the claimed products or services.

    ShortIndicator of the lead practitioner
    Comments

    Responsible might not be required when there is only a single provider listed.

    Control0..1
    Typeboolean
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When multiple parties are present it is required to distinguish the lead or responsible individual.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    118. ExplanationOfBenefit.careTeam.role
    Definition

    The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

    ShortFunction within the team
    Comments

    Role might not be required when there is only a single provider listed.

    Control0..1
    BindingFor example codes, see ClaimCareTeamRoleCodes
    (example to http://hl7.org/fhir/ValueSet/claim-careteamrole)

    The role codes for the care team members.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    When multiple parties are present it is required to distinguish the roles performed by each member.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    120. ExplanationOfBenefit.careTeam.qualification
    Definition

    The qualification of the practitioner which is applicable for this service.

    ShortPractitioner credential or specialization
    Control0..1
    BindingFor example codes, see ExampleProviderQualificationCodes
    (example to http://hl7.org/fhir/ValueSet/provider-qualification)

    Provider professional qualifications.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Need to specify which qualification a provider is delivering the product or service under.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    122. ExplanationOfBenefit.supportingInfo
    Definition

    Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

    ShortSupporting information
    Comments

    Often there are multiple jurisdiction specific valuesets which are required.

    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    124. ExplanationOfBenefit.supportingInfo.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    126. ExplanationOfBenefit.supportingInfo.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    128. ExplanationOfBenefit.supportingInfo.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    130. ExplanationOfBenefit.supportingInfo.sequence
    Definition

    A number to uniquely identify supporting information entries.

    ShortInformation instance identifier
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    132. ExplanationOfBenefit.supportingInfo.category
    Definition

    The general class of the information supplied: information; exception; accident, employment; onset, etc.

    ShortClassification of the supplied information
    Comments

    This may contain a category for the local bill type codes.

    Control1..1
    BindingFor example codes, see ClaimInformationCategoryCodes
    (example to http://hl7.org/fhir/ValueSet/claim-informationcategory)

    The valuset used for additional information category codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    134. ExplanationOfBenefit.supportingInfo.code
    Definition

    System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

    ShortType of information
    Comments

    This may contain the local bill type codes such as the US UB-04 bill type code.

    Control0..1
    BindingFor example codes, see ExceptionCodes
    (example to http://hl7.org/fhir/ValueSet/claim-exception)

    The valuset used for additional information codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required to identify the kind of additional information.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    136. ExplanationOfBenefit.supportingInfo.timing[x]
    Definition

    The date when or period to which this information refers.

    ShortWhen it occurred
    Control0..1
    TypeChoice of: date, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    138. ExplanationOfBenefit.supportingInfo.value[x]
    Definition

    Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

    ShortData to be provided
    Comments

    Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

    Control0..1
    TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    To convey the data content to be provided when the information is more than a simple code or period.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    140. ExplanationOfBenefit.supportingInfo.reason
    Definition

    Provides the reason in the situation where a reason code is required in addition to the content.

    ShortExplanation for the information
    Comments

    For example: the reason for the additional stay, or why a tooth is missing.

    Control0..1
    BindingFor example codes, see MissingToothReasonCodes
    (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason)

    Reason codes for the missing teeth.

    TypeCoding
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed when the supporting information has both a date and amount/value and requires explanation.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    142. ExplanationOfBenefit.diagnosis
    Definition

    Information about diagnoses relevant to the claim items.

    ShortPertinent diagnosis information
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required for the adjudication by provided context for the services and product listed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    144. ExplanationOfBenefit.diagnosis.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    146. ExplanationOfBenefit.diagnosis.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    148. ExplanationOfBenefit.diagnosis.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    150. ExplanationOfBenefit.diagnosis.sequence
    Definition

    A number to uniquely identify diagnosis entries.

    ShortDiagnosis instance identifier
    Comments

    Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    152. ExplanationOfBenefit.diagnosis.diagnosis[x]
    Definition

    The nature of illness or problem in a coded form or as a reference to an external defined Condition.

    ShortNature of illness or problem
    Control1..1
    BindingFor example codes, see ICD-10Codes
    (example to http://hl7.org/fhir/ValueSet/icd-10)

    ICD10 Diagnostic codes.

    TypeChoice of: CodeableConcept, Reference(Condition)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides health context for the evaluation of the products and/or services.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    154. ExplanationOfBenefit.diagnosis.type
    Definition

    When the condition was observed or the relative ranking.

    ShortTiming or nature of the diagnosis
    Comments

    For example: admitting, primary, secondary, discharge.

    Control0..*
    BindingFor example codes, see ExampleDiagnosisTypeCodes
    (example to http://hl7.org/fhir/ValueSet/ex-diagnosistype)

    The type of the diagnosis: admitting, principal, discharge.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Often required to capture a particular diagnosis, for example: primary or discharge.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    156. ExplanationOfBenefit.diagnosis.onAdmission
    Definition

    Indication of whether the diagnosis was present on admission to a facility.

    ShortPresent on admission
    Control0..1
    BindingFor example codes, see ExampleDiagnosisOnAdmissionCodes
    (example to http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission)

    Present on admission.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Many systems need to understand for adjudication if the diagnosis was present a time of admission.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    158. ExplanationOfBenefit.diagnosis.packageCode
    Definition

    A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

    ShortPackage billing code
    Comments

    For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

    Control0..1
    BindingFor example codes, see ExampleDiagnosisRelatedGroupCodes
    (example to http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup)

    The DRG codes associated with the diagnosis.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    160. ExplanationOfBenefit.procedure
    Definition

    Procedures performed on the patient relevant to the billing items with the claim.

    ShortClinical procedures performed
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    162. ExplanationOfBenefit.procedure.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    164. ExplanationOfBenefit.procedure.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    166. ExplanationOfBenefit.procedure.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    168. ExplanationOfBenefit.procedure.sequence
    Definition

    A number to uniquely identify procedure entries.

    ShortProcedure instance identifier
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Necessary to provide a mechanism to link to claim details.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    170. ExplanationOfBenefit.procedure.type
    Definition

    When the condition was observed or the relative ranking.

    ShortCategory of Procedure
    Control0..*
    BindingFor example codes, see ExampleProcedureTypeCodes
    (example to http://hl7.org/fhir/ValueSet/ex-procedure-type)

    Example procedure type codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Often required to capture a particular diagnosis, for example: primary or discharge.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    172. ExplanationOfBenefit.procedure.date
    Definition

    Date and optionally time the procedure was performed.

    ShortWhen the procedure was performed
    Control0..1
    TypedateTime
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Required for auditing purposes.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    174. ExplanationOfBenefit.procedure.procedure[x]
    Definition

    The code or reference to a Procedure resource which identifies the clinical intervention performed.

    ShortSpecific clinical procedure
    Control1..1
    BindingFor example codes, see ICD-10ProcedureCodes
    (example to http://hl7.org/fhir/ValueSet/icd-10-procedures)

    ICD10 Procedure codes.

    TypeChoice of: CodeableConcept, Reference(Procedure)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Summaryfalse
    Requirements

    This identifies the actual clinical procedure.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    176. ExplanationOfBenefit.procedure.udi
    Definition

    Unique Device Identifiers associated with this line item.

    ShortUnique device identifier
    Control0..*
    TypeReference(Device)
    Is Modifierfalse
    Summaryfalse
    Requirements

    The UDI code allows the insurer to obtain device level information on the product supplied.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    178. ExplanationOfBenefit.precedence
    Definition

    This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.

    ShortPrecedence (primary, secondary, etc.)
    Control0..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed to coordinate between multiple EOBs for the same suite of services.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    180. ExplanationOfBenefit.insurance
    Definition

    Financial instruments for reimbursement for the health care products and services specified on the claim.

    ShortPatient insurance information
    Comments

    All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

    Control1..1
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    At least one insurer is required for a claim to be a claim.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    182. ExplanationOfBenefit.insurance.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    184. ExplanationOfBenefit.insurance.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    186. ExplanationOfBenefit.insurance.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    188. ExplanationOfBenefit.insurance.focal
    Definition

    A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

    ShortCoverage to be used for adjudication
    Comments

    A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

    Control1..1
    Typeboolean
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    To identify which coverage in the list is being used to adjudicate this claim.

    Fixed Valuetrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    190. ExplanationOfBenefit.insurance.coverage
    Definition

    Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

    ShortMedicare or Veteran card information
    Comments

    Medicare or veteran card information may not be available in some records, for example if this resource describes claim information that was originally in another format.

    Control1..1
    TypeReference(Coverage)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    Required to allow the adjudicator to locate the correct policy and history within their information system.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    192. ExplanationOfBenefit.insurance.preAuthRef
    Definition

    Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

    ShortPrior authorization reference number
    Comments

    This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

    Control0..*
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    194. ExplanationOfBenefit.accident
    Definition

    Details of a accident which resulted in injuries which required the products and services listed in the claim.

    ShortDetails of the event
    Control0..1
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    196. ExplanationOfBenefit.accident.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    198. ExplanationOfBenefit.accident.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    200. ExplanationOfBenefit.accident.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    202. ExplanationOfBenefit.accident.date
    Definition

    Date of an accident event related to the products and services contained in the claim.

    ShortWhen the incident occurred
    Comments

    The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

    Control0..1
    Typedate
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Required for audit purposes and adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    204. ExplanationOfBenefit.accident.type
    Definition

    The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

    ShortThe nature of the accident
    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from ActIncidentCode
    (extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode)

    Type of accident: work place, auto, etc.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Coverage may be dependant on the type of accident.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    206. ExplanationOfBenefit.accident.location[x]
    Definition

    The physical location of the accident event.

    ShortWhere the event occurred
    Control0..1
    TypeChoice of: Address, Reference(Location)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required for audit purposes and determination of applicable insurance liability.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    208. ExplanationOfBenefit.item
    Definition

    A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

    ShortProduct or service provided
    Control1..1
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    The items to be processed for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    210. ExplanationOfBenefit.item.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    212. ExplanationOfBenefit.item.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    214. ExplanationOfBenefit.item.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    216. ExplanationOfBenefit.item.sequence
    Definition

    A number to uniquely identify item entries.

    ShortItem instance identifier
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summaryfalse
    Requirements

    Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

    Fixed Value1
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    218. ExplanationOfBenefit.item.careTeamSequence
    Definition

    Care team members related to this service or product.

    ShortApplicable care team members
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Need to identify the individuals and their roles in the provision of the product or service.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    220. ExplanationOfBenefit.item.diagnosisSequence
    Definition

    Diagnoses applicable for this service or product.

    ShortApplicable diagnoses
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Need to related the product or service to the associated diagnoses.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    222. ExplanationOfBenefit.item.procedureSequence
    Definition

    Procedures applicable for this service or product.

    ShortApplicable procedures
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Need to provide any listed specific procedures to support the product or service being claimed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    224. ExplanationOfBenefit.item.informationSequence
    Definition

    Exceptions, special conditions and supporting information applicable for this service or product.

    ShortApplicable exception and supporting information
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Need to reference the supporting information items that relate directly to this product or service.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    226. ExplanationOfBenefit.item.revenue
    Definition

    The type of revenue or cost center providing the product and/or service.

    ShortRevenue or cost center code
    Control0..1
    BindingFor example codes, see ExampleRevenueCenterCodes
    (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

    Codes for the revenue or cost centers supplying the service and/or products.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    228. ExplanationOfBenefit.item.category
    Definition

    Code to identify the general type of benefits under which products and services are provided.

    ShortBenefit classification
    Comments

    Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from Australian Medicare Benefit and Claim Category .
    (extensible to https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1)
    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    230. ExplanationOfBenefit.item.productOrService
    Definition

    The billing code the service was claimed with against the Australian Department of Health Modified PBS Schedule Item.

    ShortPBS Billing code
    Comments

    The code as instantiated may be padded with leading zeros when compared with the original (as published by the Department of Health).

    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from PBS Item Codes
    (extensible to http://terminology.hl7.org.au/ValueSet/pbs-item)
    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    232. ExplanationOfBenefit.item.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortProduct or service billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    234. ExplanationOfBenefit.item.programCode
    Definition

    Identifies the program under which this may be recovered.

    ShortProgram the product or service is provided under
    Comments

    For example: Neonatal program, child dental program or drug users recovery program.

    Control0..*
    BindingFor example codes, see ExampleProgramReasonCodes
    (example to http://hl7.org/fhir/ValueSet/ex-program-code)

    Program specific reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    236. ExplanationOfBenefit.item.serviced[x]
    Definition

    The date or dates when the service or product was supplied, performed or completed.

    ShortDate or dates of service or product delivery
    Control1..1
    TypeChoice of: date, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summaryfalse
    Requirements

    Needed to determine whether the service or product was provided during the term of the insurance coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    238. ExplanationOfBenefit.item.location[x]
    Definition

    Where the product or service was provided.

    ShortPlace of service or where product was supplied
    Control0..1
    BindingFor example codes, see ExampleServicePlaceCodes
    (example to http://hl7.org/fhir/ValueSet/service-place)

    Place where the service is rendered.

    TypeChoice of: CodeableConcept, Address, Reference(Location)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Summaryfalse
    Requirements

    The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    240. ExplanationOfBenefit.item.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    242. ExplanationOfBenefit.item.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    244. ExplanationOfBenefit.item.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    246. ExplanationOfBenefit.item.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    248. ExplanationOfBenefit.item.udi
    Definition

    Unique Device Identifiers associated with this line item.

    ShortUnique device identifier
    Control0..*
    TypeReference(Device)
    Is Modifierfalse
    Summaryfalse
    Requirements

    The UDI code allows the insurer to obtain device level information on the product supplied.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    250. ExplanationOfBenefit.item.bodySite
    Definition

    Physical service site on the patient (limb, tooth, etc.).

    ShortAnatomical location
    Comments

    For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

    Control0..1
    BindingFor example codes, see OralSiteCodes
    (example to http://hl7.org/fhir/ValueSet/tooth)

    The code for the teeth, quadrant, sextant and arch.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Allows insurer to validate specific procedures.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    252. ExplanationOfBenefit.item.subSite
    Definition

    A region or surface of the bodySite, e.g. limb region or tooth surface(s).

    ShortAnatomical sub-location
    Control0..*
    BindingFor example codes, see SurfaceCodes
    (example to http://hl7.org/fhir/ValueSet/surface)

    The code for the tooth surface and surface combinations.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Allows insurer to validate specific procedures.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    254. ExplanationOfBenefit.item.encounter
    Definition

    A billed item may include goods or services provided in multiple encounters.

    ShortEncounters related to this billed item
    Control0..*
    TypeReference(Encounter)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Used in some jurisdictions to link clinical events to claim items.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    256. ExplanationOfBenefit.item.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    258. ExplanationOfBenefit.item.adjudication
    Definition

    If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

    ShortAdjudication details
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    260. ExplanationOfBenefit.item.adjudication.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    262. ExplanationOfBenefit.item.adjudication.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    264. ExplanationOfBenefit.item.adjudication.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    266. ExplanationOfBenefit.item.adjudication.category
    Definition

    A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

    ShortType of adjudication information
    Comments

    For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

    Control1..1
    BindingFor example codes, see AdjudicationValueCodes
    (example to http://hl7.org/fhir/ValueSet/adjudication)

    The adjudication codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to enable understanding of the context of the other information in the adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    268. ExplanationOfBenefit.item.adjudication.reason
    Definition

    A code supporting the understanding of the adjudication result and explaining variance from expected amount.

    ShortExplanation of adjudication outcome
    Comments

    For example, may indicate that the funds for this benefit type have been exhausted.

    Control0..1
    BindingFor example codes, see AdjudicationReasonCodes
    (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

    Adjudication reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support understanding of variance from adjudication expectations.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    270. ExplanationOfBenefit.item.adjudication.amount
    Definition

    Monetary amount associated with the category.

    ShortMonetary amount
    Comments

    For example, amount submitted, eligible amount, co-payment, and benefit payable.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Most adjuciation categories convey a monetary amount.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    272. ExplanationOfBenefit.item.adjudication.value
    Definition

    A non-monetary value associated with the category. Mutually exclusive to the amount element above.

    ShortNon-monitary value
    Comments

    For example: eligible percentage or co-payment percentage.

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Some adjudication categories convey a percentage or a fixed value.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    274. ExplanationOfBenefit.item.detail
    Definition

    Second-tier of goods and services.

    ShortAdditional items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    276. ExplanationOfBenefit.item.detail.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    278. ExplanationOfBenefit.item.detail.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    280. ExplanationOfBenefit.item.detail.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    282. ExplanationOfBenefit.item.detail.sequence
    Definition

    A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

    ShortProduct or service provided
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    The items to be processed for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    284. ExplanationOfBenefit.item.detail.revenue
    Definition

    The type of revenue or cost center providing the product and/or service.

    ShortRevenue or cost center code
    Control0..1
    BindingFor example codes, see ExampleRevenueCenterCodes
    (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

    Codes for the revenue or cost centers supplying the service and/or products.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    286. ExplanationOfBenefit.item.detail.category
    Definition

    Code to identify the general type of benefits under which products and services are provided.

    ShortBenefit classification
    Comments

    Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

    Control0..1
    BindingFor example codes, see BenefitCategoryCodes
    (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

    Benefit categories such as: oral, medical, vision, oral-basic etc.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    288. ExplanationOfBenefit.item.detail.productOrService
    Definition

    When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

    ShortBilling, service, product, or drug code
    Comments

    If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

    Control1..1
    BindingFor example codes, see USCLSCodes
    (example to http://hl7.org/fhir/ValueSet/service-uscls)

    Allowable service and product codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    290. ExplanationOfBenefit.item.detail.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortService/Product billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    292. ExplanationOfBenefit.item.detail.programCode
    Definition

    Identifies the program under which this may be recovered.

    ShortProgram the product or service is provided under
    Comments

    For example: Neonatal program, child dental program or drug users recovery program.

    Control0..*
    BindingFor example codes, see ExampleProgramReasonCodes
    (example to http://hl7.org/fhir/ValueSet/ex-program-code)

    Program specific reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    294. ExplanationOfBenefit.item.detail.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    296. ExplanationOfBenefit.item.detail.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    298. ExplanationOfBenefit.item.detail.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    300. ExplanationOfBenefit.item.detail.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    302. ExplanationOfBenefit.item.detail.udi
    Definition

    Unique Device Identifiers associated with this line item.

    ShortUnique device identifier
    Control0..*
    TypeReference(Device)
    Is Modifierfalse
    Summaryfalse
    Requirements

    The UDI code allows the insurer to obtain device level information on the product supplied.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    304. ExplanationOfBenefit.item.detail.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    306. ExplanationOfBenefit.item.detail.adjudication
    Definition

    The adjudication results.

    ShortDetail level adjudication details
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    308. ExplanationOfBenefit.item.detail.subDetail
    Definition

    Third-tier of goods and services.

    ShortAdditional items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    310. ExplanationOfBenefit.item.detail.subDetail.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    312. ExplanationOfBenefit.item.detail.subDetail.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    314. ExplanationOfBenefit.item.detail.subDetail.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    316. ExplanationOfBenefit.item.detail.subDetail.sequence
    Definition

    A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

    ShortProduct or service provided
    Control1..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    The items to be processed for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    318. ExplanationOfBenefit.item.detail.subDetail.revenue
    Definition

    The type of revenue or cost center providing the product and/or service.

    ShortRevenue or cost center code
    Control0..1
    BindingFor example codes, see ExampleRevenueCenterCodes
    (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

    Codes for the revenue or cost centers supplying the service and/or products.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    320. ExplanationOfBenefit.item.detail.subDetail.category
    Definition

    Code to identify the general type of benefits under which products and services are provided.

    ShortBenefit classification
    Comments

    Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

    Control0..1
    BindingFor example codes, see BenefitCategoryCodes
    (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

    Benefit categories such as: oral, medical, vision, oral-basic etc.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    322. ExplanationOfBenefit.item.detail.subDetail.productOrService
    Definition

    When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

    ShortBilling, service, product, or drug code
    Comments

    If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

    Control1..1
    BindingFor example codes, see USCLSCodes
    (example to http://hl7.org/fhir/ValueSet/service-uscls)

    Allowable service and product codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    324. ExplanationOfBenefit.item.detail.subDetail.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortService/Product billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    326. ExplanationOfBenefit.item.detail.subDetail.programCode
    Definition

    Identifies the program under which this may be recovered.

    ShortProgram the product or service is provided under
    Comments

    For example: Neonatal program, child dental program or drug users recovery program.

    Control0..*
    BindingFor example codes, see ExampleProgramReasonCodes
    (example to http://hl7.org/fhir/ValueSet/ex-program-code)

    Program specific reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    328. ExplanationOfBenefit.item.detail.subDetail.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    330. ExplanationOfBenefit.item.detail.subDetail.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    332. ExplanationOfBenefit.item.detail.subDetail.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    334. ExplanationOfBenefit.item.detail.subDetail.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    336. ExplanationOfBenefit.item.detail.subDetail.udi
    Definition

    Unique Device Identifiers associated with this line item.

    ShortUnique device identifier
    Control0..*
    TypeReference(Device)
    Is Modifierfalse
    Summaryfalse
    Requirements

    The UDI code allows the insurer to obtain device level information on the product supplied.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    338. ExplanationOfBenefit.item.detail.subDetail.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    340. ExplanationOfBenefit.item.detail.subDetail.adjudication
    Definition

    The adjudication results.

    ShortSubdetail level adjudication details
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    342. ExplanationOfBenefit.addItem
    Definition

    The first-tier service adjudications for payor added product or service lines.

    ShortInsurer added line items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    344. ExplanationOfBenefit.addItem.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    346. ExplanationOfBenefit.addItem.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    348. ExplanationOfBenefit.addItem.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    350. ExplanationOfBenefit.addItem.itemSequence
    Definition

    Claim items which this service line is intended to replace.

    ShortItem sequence number
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides references to the claim items.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    352. ExplanationOfBenefit.addItem.detailSequence
    Definition

    The sequence number of the details within the claim item which this line is intended to replace.

    ShortDetail sequence number
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides references to the claim details within the claim item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    354. ExplanationOfBenefit.addItem.subDetailSequence
    Definition

    The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

    ShortSubdetail sequence number
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides references to the claim sub-details within the claim detail.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    356. ExplanationOfBenefit.addItem.provider
    Definition

    The providers who are authorized for the services rendered to the patient.

    ShortAuthorized providers
    Control0..*
    TypeReference(Practitioner, PractitionerRole, Organization)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    358. ExplanationOfBenefit.addItem.productOrService
    Definition

    When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

    ShortBilling, service, product, or drug code
    Comments

    If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

    Control1..1
    BindingFor example codes, see USCLSCodes
    (example to http://hl7.org/fhir/ValueSet/service-uscls)

    Allowable service and product codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    360. ExplanationOfBenefit.addItem.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortService/Product billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    362. ExplanationOfBenefit.addItem.programCode
    Definition

    Identifies the program under which this may be recovered.

    ShortProgram the product or service is provided under
    Comments

    For example: Neonatal program, child dental program or drug users recovery program.

    Control0..*
    BindingFor example codes, see ExampleProgramReasonCodes
    (example to http://hl7.org/fhir/ValueSet/ex-program-code)

    Program specific reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    364. ExplanationOfBenefit.addItem.serviced[x]
    Definition

    The date or dates when the service or product was supplied, performed or completed.

    ShortDate or dates of service or product delivery
    Control0..1
    TypeChoice of: date, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed to determine whether the service or product was provided during the term of the insurance coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    366. ExplanationOfBenefit.addItem.location[x]
    Definition

    Where the product or service was provided.

    ShortPlace of service or where product was supplied
    Control0..1
    BindingFor example codes, see ExampleServicePlaceCodes
    (example to http://hl7.org/fhir/ValueSet/service-place)

    Place where the service is rendered.

    TypeChoice of: CodeableConcept, Address, Reference(Location)
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Summaryfalse
    Requirements

    The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    368. ExplanationOfBenefit.addItem.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    370. ExplanationOfBenefit.addItem.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    372. ExplanationOfBenefit.addItem.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    374. ExplanationOfBenefit.addItem.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    376. ExplanationOfBenefit.addItem.bodySite
    Definition

    Physical service site on the patient (limb, tooth, etc.).

    ShortAnatomical location
    Comments

    For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

    Control0..1
    BindingFor example codes, see OralSiteCodes
    (example to http://hl7.org/fhir/ValueSet/tooth)

    The code for the teeth, quadrant, sextant and arch.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Allows insurer to validate specific procedures.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    378. ExplanationOfBenefit.addItem.subSite
    Definition

    A region or surface of the bodySite, e.g. limb region or tooth surface(s).

    ShortAnatomical sub-location
    Control0..*
    BindingFor example codes, see SurfaceCodes
    (example to http://hl7.org/fhir/ValueSet/surface)

    The code for the tooth surface and surface combinations.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Allows insurer to validate specific procedures.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    380. ExplanationOfBenefit.addItem.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    382. ExplanationOfBenefit.addItem.adjudication
    Definition

    The adjudication results.

    ShortAdded items adjudication
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    384. ExplanationOfBenefit.addItem.detail
    Definition

    The second-tier service adjudications for payor added services.

    ShortInsurer added line items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    386. ExplanationOfBenefit.addItem.detail.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    388. ExplanationOfBenefit.addItem.detail.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    390. ExplanationOfBenefit.addItem.detail.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    392. ExplanationOfBenefit.addItem.detail.productOrService
    Definition

    When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

    ShortBilling, service, product, or drug code
    Comments

    If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

    Control1..1
    BindingFor example codes, see USCLSCodes
    (example to http://hl7.org/fhir/ValueSet/service-uscls)

    Allowable service and product codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    394. ExplanationOfBenefit.addItem.detail.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortService/Product billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    396. ExplanationOfBenefit.addItem.detail.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    398. ExplanationOfBenefit.addItem.detail.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    400. ExplanationOfBenefit.addItem.detail.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    402. ExplanationOfBenefit.addItem.detail.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    404. ExplanationOfBenefit.addItem.detail.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    406. ExplanationOfBenefit.addItem.detail.adjudication
    Definition

    The adjudication results.

    ShortAdded items adjudication
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    408. ExplanationOfBenefit.addItem.detail.subDetail
    Definition

    The third-tier service adjudications for payor added services.

    ShortInsurer added line items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    410. ExplanationOfBenefit.addItem.detail.subDetail.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    412. ExplanationOfBenefit.addItem.detail.subDetail.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    414. ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    416. ExplanationOfBenefit.addItem.detail.subDetail.productOrService
    Definition

    When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

    ShortBilling, service, product, or drug code
    Comments

    If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

    Control1..1
    BindingFor example codes, see USCLSCodes
    (example to http://hl7.org/fhir/ValueSet/service-uscls)

    Allowable service and product codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Necessary to state what was provided or done.

    Alternate NamesDrug Code, Bill Code, Service Code
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    418. ExplanationOfBenefit.addItem.detail.subDetail.modifier
    Definition

    Item typification or modifiers codes to convey additional context for the product or service.

    ShortService/Product billing modifiers
    Comments

    For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

    Control0..*
    BindingFor example codes, see ModifierTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

    Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To support inclusion of the item for adjudication or to charge an elevated fee.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    420. ExplanationOfBenefit.addItem.detail.subDetail.quantity
    Definition

    The number of repetitions of a service or product.

    ShortCount of products or services
    Control0..1
    TypeQuantity(SimpleQuantity)
    Is Modifierfalse
    Summaryfalse
    Requirements

    Required when the product or service code does not convey the quantity provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    422. ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
    Definition

    If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

    ShortFee, charge or cost per item
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    The amount charged to the patient by the provider for a single unit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    424. ExplanationOfBenefit.addItem.detail.subDetail.factor
    Definition

    A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

    ShortPrice scaling factor
    Comments

    To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

    Control0..1
    Typedecimal
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    426. ExplanationOfBenefit.addItem.detail.subDetail.net
    Definition

    The quantity times the unit price for an additional service or product or charge.

    ShortTotal item cost
    Comments

    For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the total amount claimed for the group (if a grouper) or the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    428. ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
    Definition

    The numbers associated with notes below which apply to the adjudication of this item.

    ShortApplicable note numbers
    Control0..*
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    430. ExplanationOfBenefit.addItem.detail.subDetail.adjudication
    Definition

    The adjudication results.

    ShortAdded items adjudication
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    432. ExplanationOfBenefit.adjudication
    Definition

    The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

    ShortHeader-level adjudication
    Control0..*
    TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
    Is Modifierfalse
    Summaryfalse
    Requirements

    Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    434. ExplanationOfBenefit.total
    Definition

    Categorized monetary totals for the adjudication.

    ShortAdjudication totals
    Comments

    Totals for amounts submitted, co-pays, benefits payable etc.

    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summarytrue
    Requirements

    To provide the requestor with financial totals by category for the adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    436. ExplanationOfBenefit.total.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    438. ExplanationOfBenefit.total.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    440. ExplanationOfBenefit.total.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    442. ExplanationOfBenefit.total.category
    Definition

    A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

    ShortType of adjudication information
    Comments

    For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

    Control1..1
    BindingFor example codes, see AdjudicationValueCodes
    (example to http://hl7.org/fhir/ValueSet/adjudication)

    The adjudication codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Needed to convey the type of total provided.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    444. ExplanationOfBenefit.total.amount
    Definition

    Monetary total amount associated with the category.

    ShortFinancial total for the category
    Control1..1
    TypeMoney
    Is Modifierfalse
    Summarytrue
    Requirements

    Needed to convey the total monetary amount.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    446. ExplanationOfBenefit.payment
    Definition

    Payment details for the adjudication of the claim.

    ShortPayment Details
    Control0..1
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to convey references to the financial instrument that has been used if payment has been made.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    448. ExplanationOfBenefit.payment.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    450. ExplanationOfBenefit.payment.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    452. ExplanationOfBenefit.payment.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    454. ExplanationOfBenefit.payment.type
    Definition

    Whether this represents partial or complete payment of the benefits payable.

    ShortPartial or complete payment
    Control0..1
    BindingFor example codes, see ExamplePaymentTypeCodes
    (example to http://hl7.org/fhir/ValueSet/ex-paymenttype)

    The type (partial, complete) of the payment.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    To advise the requestor when the insurer believes all payments to have been completed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    456. ExplanationOfBenefit.payment.adjustment
    Definition

    Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

    ShortPayment adjustment for non-claim issues
    Comments

    Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    To advise the requestor of adjustments applied to the payment.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    458. ExplanationOfBenefit.payment.adjustmentReason
    Definition

    Reason for the payment adjustment.

    ShortExplanation for the variance
    Control0..1
    BindingFor example codes, see PaymentAdjustmentReasonCodes
    (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason)

    Payment Adjustment reason codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to clarify the monetary adjustment.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    460. ExplanationOfBenefit.payment.date
    Definition

    Estimated date the payment will be issued or the actual issue date of payment.

    ShortExpected date of payment
    Control0..1
    Typedate
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    To advise the payee when payment can be expected.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    462. ExplanationOfBenefit.payment.amount
    Definition

    Benefits payable less any payment adjustment.

    ShortPayable amount after adjustment
    Control0..1
    TypeMoney
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to provide the actual payment amount.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    464. ExplanationOfBenefit.payment.identifier
    Definition

    Issuer's unique identifier for the payment instrument.

    ShortBusiness identifier for the payment
    Comments

    For example: EFT number or check number.

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..1
    TypeIdentifier
    Is Modifierfalse
    Summaryfalse
    Requirements

    Enable the receiver to reconcile when payment received.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    466. ExplanationOfBenefit.formCode
    Definition

    A code for the form to be used for printing the content.

    ShortPrinted form identifier
    Comments

    May be needed to identify specific jurisdictional forms.

    Control0..1
    BindingFor example codes, see Form Codes
    (example to http://hl7.org/fhir/ValueSet/forms)

    The forms codes.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to specify the specific form used for producing output for this response.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    468. ExplanationOfBenefit.form
    Definition

    The actual form, by reference or inclusion, for printing the content or an EOB.

    ShortPrinted reference or actual form
    Comments

    Needed to permit insurers to include the actual form.

    Control0..1
    TypeAttachment
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to include the specific form used for producing output for this response.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    470. ExplanationOfBenefit.processNote
    Definition

    A note that describes or explains adjudication results in a human readable form.

    ShortNote concerning adjudication
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Requirements

    Provides the insurer specific textual explanations associated with the processing.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    472. ExplanationOfBenefit.processNote.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    474. ExplanationOfBenefit.processNote.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    476. ExplanationOfBenefit.processNote.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    478. ExplanationOfBenefit.processNote.number
    Definition

    A number to uniquely identify a note entry.

    ShortNote instance identifier
    Control0..1
    TypepositiveInt
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Necessary to provide a mechanism to link from adjudications.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    480. ExplanationOfBenefit.processNote.type
    Definition

    The business purpose of the note text.

    Shortdisplay | print | printoper
    Control0..1
    BindingThe codes SHALL be taken from NoteType
    (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)

    The presentation types of notes.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    To convey the expectation for when the text is used.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    482. ExplanationOfBenefit.processNote.text
    Definition

    The explanation or description associated with the processing.

    ShortNote explanatory text
    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Required to provide human readable explanation.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    484. ExplanationOfBenefit.processNote.language
    Definition

    A code to define the language used in the text of the note.

    ShortLanguage of the text
    Comments

    Only required if the language is different from the resource language.

    Control0..1
    BindingThe codes SHOULD be taken from CommonLanguages
    (preferred to http://hl7.org/fhir/ValueSet/languages)

    A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Note text may vary from the resource defined language.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    486. ExplanationOfBenefit.benefitPeriod
    Definition

    The term of the benefits documented in this response.

    ShortWhen the benefits are applicable
    Comments

    Not applicable when use=claim.

    Control0..1
    TypePeriod
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    488. ExplanationOfBenefit.benefitBalance
    Definition

    Balance by Benefit Category.

    ShortBalance by Benefit Category
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    490. ExplanationOfBenefit.benefitBalance.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    492. ExplanationOfBenefit.benefitBalance.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    494. ExplanationOfBenefit.benefitBalance.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    496. ExplanationOfBenefit.benefitBalance.category
    Definition

    Code to identify the general type of benefits under which products and services are provided.

    ShortBenefit classification
    Comments

    Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

    Control1..1
    BindingFor example codes, see BenefitCategoryCodes
    (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

    Benefit categories such as: oral, medical, vision, oral-basic etc.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to convey the category of service or product for which eligibility is sought.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    498. ExplanationOfBenefit.benefitBalance.excluded
    Definition

    True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

    ShortExcluded from the plan
    Control0..1
    Typeboolean
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed to identify items that are specifically excluded from the coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    500. ExplanationOfBenefit.benefitBalance.name
    Definition

    A short name or tag for the benefit.

    ShortShort name for the benefit
    Comments

    For example: MED01, or DENT2.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Required to align with other plan names.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    502. ExplanationOfBenefit.benefitBalance.description
    Definition

    A richer description of the benefit or services covered.

    ShortDescription of the benefit or services covered
    Comments

    For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed for human readable reference.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    504. ExplanationOfBenefit.benefitBalance.network
    Definition

    Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

    ShortIn or out of network
    Control0..1
    BindingFor example codes, see NetworkTypeCodes
    (example to http://hl7.org/fhir/ValueSet/benefit-network)

    Code to classify in or out of network services.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed as in or out of network providers are treated differently under the coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    506. ExplanationOfBenefit.benefitBalance.unit
    Definition

    Indicates if the benefits apply to an individual or to the family.

    ShortIndividual or family
    Control0..1
    BindingFor example codes, see UnitTypeCodes
    (example to http://hl7.org/fhir/ValueSet/benefit-unit)

    Unit covered/serviced - individual or family.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed for the understanding of the benefits.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    508. ExplanationOfBenefit.benefitBalance.term
    Definition

    The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

    ShortAnnual or lifetime
    Control0..1
    BindingFor example codes, see BenefitTermCodes
    (example to http://hl7.org/fhir/ValueSet/benefit-term)

    Coverage unit - annual, lifetime.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed for the understanding of the benefits.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    510. ExplanationOfBenefit.benefitBalance.financial
    Definition

    Benefits Used to date.

    ShortBenefit Summary
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    512. ExplanationOfBenefit.benefitBalance.financial.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    514. ExplanationOfBenefit.benefitBalance.financial.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    516. ExplanationOfBenefit.benefitBalance.financial.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    518. ExplanationOfBenefit.benefitBalance.financial.type
    Definition

    Classification of benefit being provided.

    ShortBenefit classification
    Comments

    For example: deductible, visits, benefit amount.

    Control1..1
    BindingFor example codes, see BenefitTypeCodes
    (example to http://hl7.org/fhir/ValueSet/benefit-type)

    Deductable, visits, co-pay, etc.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Needed to convey the nature of the benefit.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    520. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
    Definition

    The quantity of the benefit which is permitted under the coverage.

    ShortBenefits allowed
    Control0..1
    TypeChoice of: unsignedInt, string, Money
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed to convey the benefits offered under the coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    522. ExplanationOfBenefit.benefitBalance.financial.used[x]
    Definition

    The quantity of the benefit which have been consumed to date.

    ShortBenefits used
    Control0..1
    TypeChoice of: unsignedInt, Money
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Needed to convey the benefits consumed to date.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))