My Health Record FHIR IG - Local Development build (v1.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: ADHA Record of Claim against PBS or RPBS

The purpose of this profile is to define a representation of a record of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

Usage:

• Examples for this Resource Profile: ExplanationOfBenefit/pbs-cont-01, ExplanationOfBenefit/pbs-cont-02 and ExplanationOfBenefit/pbs-mds

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
identifier	S	1..*	Identifier	Business Identifier for the resource
status	S	1..1	code	active | cancelled | draft | entered-in-error Fixed Value: active
type	S	1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	S	1..1	code	claim | preauthorization | predetermination Fixed Value: claim
patient	SC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
created	SC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
insurer	SC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	S	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
reference		1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	code	queued | complete | error | partial Fixed Value: complete
insurance	S	1..1	BackboneElement	Patient insurance information
focal	S	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	S	1..1	Reference(Coverage)	Medicare or Veteran card information
item	S	1..1	BackboneElement	Product or service provided
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
serviced[x]	S	1..1	date, Period	Date or dates of service or product delivery
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
patient	SΣC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
created	SΣC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
insurer	SΣC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	SΣ	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
insurance	SΣ	1..1	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	SΣ	1..1	Reference(Coverage)	Medicare or Veteran card information
item	S	1..1	BackboneElement	Product or service provided
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
serviced[x]	S	1..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: pharmacy http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use	required	Fixed Value: claim http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.outcome	required	Fixed Value: complete http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
patient	SΣC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	SΣC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	SΣ	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
originalPrescription		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment Referral
facility		0..1	Reference(Location)	Servicing Facility
claim		0..1	Reference(Claim)	Claim reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
disposition		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference
preAuthRefPeriod		0..*	Period	Preauthorization in-effect period
careTeam		0..*	BackboneElement	Care Team members
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo		0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	SΣ	1..1	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	SΣ	1..1	Reference(Coverage)	Medicare or Veteran card information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item	S	1..1	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
careTeamSequence		0..*	positiveInt	Applicable care team members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	1..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
detail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details
subDetail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subDetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		0..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
benefitPeriod		0..1	Period	When the benefits are applicable
benefitBalance		0..*	BackboneElement	Balance by Benefit Category
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedMoney			Money
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: pharmacy http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use	required	Fixed Value: claim http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequested	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard
ExplanationOfBenefit.prescription.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
ExplanationOfBenefit.outcome	required	Fixed Value: complete http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.careTeam.role	example	ClaimCareTeamRoleCodes http://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
ExplanationOfBenefit.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard
ExplanationOfBenefit.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.benefitBalance.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.benefitBalance.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 7 elements
Must-Support: 20 elements
Fixed: 5 elements

Structures

This structure refers to these other structures:

• ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
• ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
• ADHA Core PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-core-1)
• ADHA PBS Claim Item (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-medicationrequest-pbs-claim-1)

Differential View

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
identifier	S	1..*	Identifier	Business Identifier for the resource
status	S	1..1	code	active | cancelled | draft | entered-in-error Fixed Value: active
type	S	1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	S	1..1	code	claim | preauthorization | predetermination Fixed Value: claim
patient	SC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
created	SC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
insurer	SC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	S	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
reference		1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	code	queued | complete | error | partial Fixed Value: complete
insurance	S	1..1	BackboneElement	Patient insurance information
focal	S	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	S	1..1	Reference(Coverage)	Medicare or Veteran card information
item	S	1..1	BackboneElement	Product or service provided
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
serviced[x]	S	1..1	date, Period	Date or dates of service or product delivery
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
patient	SΣC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
created	SΣC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
insurer	SΣC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	SΣ	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
insurance	SΣ	1..1	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	SΣ	1..1	Reference(Coverage)	Medicare or Veteran card information
item	S	1..1	BackboneElement	Product or service provided
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
serviced[x]	S	1..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: pharmacy http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use	required	Fixed Value: claim http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.outcome	required	Fixed Value: complete http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Record of Claim against PBS or RPBS
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subType	S	1..1	CodeableConcept	More granular claim type Binding: Australian Medicare Benefit and Claim Category (required)
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
patient	SΣC	1..1	Reference(ADHA Core Patient)	The recipient of the products and services inv-dh-eob-01: At least reference or a valid identifier shall be present
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	SΣC	1..1	dateTime	Response creation date inv-dh-eob-03: Date shall be at least to day
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣC	1..1	Reference(ADHA Core Organization)	Australian Government department that subsidises the benefits scheme inv-dh-eob-02: At least reference or a valid identifier shall be present
provider	SΣ	1..1	Reference(ADHA Core PractitionerRole)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (example)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription	S	1..1	Reference(ADHA PBS Claim Item)	Prescription authorizing services or products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
originalPrescription		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment Referral
facility		0..1	Reference(Location)	Servicing Facility
claim		0..1	Reference(Claim)	Claim reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
disposition		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference
preAuthRefPeriod		0..*	Period	Preauthorization in-effect period
careTeam		0..*	BackboneElement	Care Team members
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo		0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	SΣ	1..1	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
coverage	SΣ	1..1	Reference(Coverage)	Medicare or Veteran card information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item	S	1..1	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier Fixed Value: 1
careTeamSequence		0..*	positiveInt	Applicable care team members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category	S	1..1	CodeableConcept	Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible)
productOrService	S	1..1	CodeableConcept	PBS Billing code Binding: PBS Item Codes (extensible)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	1..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
detail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details
subDetail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subDetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		0..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
benefitPeriod		0..1	Period	When the benefits are applicable
benefitBalance		0..*	BackboneElement	Balance by Benefit Category
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedMoney			Money
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: pharmacy http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.subType	required	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use	required	Fixed Value: claim http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequested	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard
ExplanationOfBenefit.prescription.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
ExplanationOfBenefit.outcome	required	Fixed Value: complete http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.careTeam.role	example	ClaimCareTeamRoleCodes http://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.category	extensible	AustralianMedicareBenefitAndClaimCategory https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService	extensible	PBSItemCodes http://terminology.hl7.org.au/ValueSet/pbs-item
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
ExplanationOfBenefit.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard
ExplanationOfBenefit.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.benefitBalance.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.benefitBalance.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-eob-01	error	ExplanationOfBenefit.patient	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02	error	ExplanationOfBenefit.insurer	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03	error	ExplanationOfBenefit.created	Date shall be at least to day : toString().length() >= 10

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 7 elements
Must-Support: 20 elements
Fixed: 5 elements

Structures

This structure refers to these other structures:

• ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
• ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
• ADHA Core PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-core-1)
• ADHA PBS Claim Item (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-medicationrequest-pbs-claim-1)