Medicare Records FHIR Implementation Guide version 1.0.0

1.0 StructureDefinition-explanationofbenefit-medicare

This profile defines a representation of Pharmaceutical Benefits Schedule (PBS) claim items or Medicare Benefits Schedule (MBS) claim items. PBS claim items include information about pharmaceutical items prescribed and dispensed to an individual that were partially or fully funded under the PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS). MBS claim items include information about healthcare services provided to an individual that were partially or fully funded by Medicare or the Department of Veterans’ Affairs.

Usage Scenarios

The following are the usage scenarios expected:

  • DHS Medicare sends MBS records to the My Health Record system
  • DHS Medicare sends PBS records to the My Health Record system
Each Explanation of Benefit SHALL have
  1. a profile assertion to this profile
  2. an identifier for this explanation of benefit record
  3. a patient
  4. a creation date
  5. an identification of the Medicare benefit (subtype or item.category)
  6. an item that was claimed
  7. a date of supply or service
Must Support

In the context of this profile Must Support SHALL be interpreted as follows.

  • The system SHALL be able to store and retrieve the following elements:
    • status
    • type
    • subtype
    • created
    • provider
    • referral
    • prescription
    • item
    • item.sequence
    • item.category
    • item.service
    • item.serviced
    • item.quantity
  • The system SHALL be able to take the following elements into account when performing processing:
    • identifier
    • patient
Profile-specific implementation guidance
  • The patient resource should be identified in the patient element with a logical reference, i.e. an Australian IHI
  • If a resource is referenced rather than identified in the applicable element, the referenced resource should be contained
  • PBS record:
    • An ExplanationOfBenefit for a PBS record will represent prescription data as a MedicationRequest, including date of prescribing, number of repeats, and quantity
    • Generic name of a PBS item can be represented by the supplied item service code
    • Date of supply of the item is represented by item.serviced[x]
  • MBS record:
    • An ExplanationOfBenefit for an MBS record will represent the requester of the service as part of a ReferralRequest
    • Whether a service was provided in a hospital is indicated by the use and value of item.location
    • Date of service is represented by item.serviced[x]
Examples
  1. Explanation of Benefit MBS example 1
  2. Explanation of Benefit MBS example 2
  3. Explanation of Benefit MBS example min
  4. Explanation of Benefit PBS example 1
  5. Explanation of Benefit PBS example 2

1.0.1 Formal Views of Profile Content

The official URL for this profile is:

http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare

This profile defines a representation of Pharmaceutical Benefits Schedule (PBS) claim items or Medicare Benefits Schedule (MBS) claim items.

This profile builds on ExplanationOfBenefit.

This profile was published on Tue Aug 28 00:00:00 AEST 2018 as a active by Australian Digital Health Agency.

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

This structure is derived from the STU3 FHIR® resource Explanation of Benefit.

This profile introduces the following variations from the above core resource:

  1. Conditional invariants
    • inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
    • inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
    • inv-dh-eob-03: One of subType or item.category SHALL be present.
    • inv-dh-eob-04: A PBS claim (subType=’pbs’) SHALL be of type ‘Pharmacy’ (type=’pharmacy’).
  2. One meta.profile is ‘http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare’
  3. Exactly one identifier
  4. status is ‘active’
  5. subType required binding to Australian Medicare Benefit and Claim Category value set
  6. Exactly one patient
  7. patient as AU Base Patient
  8. Exactly one created
  9. insurer as AU Base Organisation
  10. provider as AU Base Practitioner
  11. organization as AU Base Organisation
  12. referral contained as Referral Request Medicare Benefits Schedule Department of Veterans’ Affairs
  13. prescription contained as Medication Request Pharmaceutical Benefits Scheme
  14. Exactly one item
  15. item.sequence is ‘1’
  16. item.category extensible binding to Australian Medicare Benefit and Claim Category value set
  17. Exactly one item.service
  18. item.service required binding to Australian Department of Human Services Modifications of Pharmaceutical Benefits Scheme Schedule Item, Medicare Benefits Schedule Item and Department of Veterans’ Affairs Fee Schedule Item value set
  19. Exactly one item.serviced
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim (subType='pbs') SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... meta 1..1Meta
.... profile 1..*uri
... identifier S1..1Identifier
... status S0..1codeFixed Value: active
... type S0..1CodeableConcept
... subType S0..*CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)
... created S1..1dateTime
... insurer 0..1Reference(AU Base Organisation)
... provider S0..1Reference(AU Base Practitioner)
... organization 0..1Reference(AU Base Organisation)
... referral S0..1Reference(ReferralRequestMedicareBenefitsScheduleDepartmentofVeterans'Affairs) {c}
... prescription S0..1Reference(MedicationRequestPharmaceuticalBenefitsScheme) {c}
... item S1..1BackboneElement
.... sequence S1..1positiveIntFixed Value: 1
.... category S0..1CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... serviced[x] S1..1date, Period
.... quantity S0..1SimpleQuantity

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*Explanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim (subType='pbs') SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... id Σ0..1idLogical id of this artifact
... meta Σ1..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ1..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: Common Tags (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier
... status ?!SΣ0..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
Fixed Value: active
... type S0..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created S1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... referral S0..1Reference(ReferralRequestMedicareBenefitsScheduleDepartmentofVeterans'Affairs) {c}Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Binding: Claim Processing Codes (example)
... disposition 0..1stringDisposition Message
... related I0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: Example Related Claim Relationship Codes (example)
.... reference 0..1IdentifierRelated file or case reference
... prescription S0..1Reference(MedicationRequestPharmaceuticalBenefitsScheme) {c}Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee I0..1BackboneElementParty to be paid any benefits payable
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Binding: Claim Payee Type Codes (example)
.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
Binding: PayeeResourceType (required)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... information I0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
.... code 0..1CodeableConceptType of information
Binding: Exception Codes (example)
.... timing[x] 0..1date, PeriodWhen it occurred
.... value[x] 0..1string, Quantity, Attachment, Reference(Resource)Additional Data or supporting information
.... reason 0..1CodingReason associated with the information
Binding: Missing Tooth Reason Codes (example)
... careTeam I0..*BackboneElementCare Team members
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Binding: Example Provider Qualification Codes (example)
... diagnosis I0..*BackboneElementList of Diagnosis
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1CodeableConcept, Reference(Condition)Patient's diagnosis
Binding: ICD-10 Codes (example)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example)
.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example)
... procedure I0..*BackboneElementProcedures performed
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1CodeableConcept, Reference(Procedure)Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance I0..1BackboneElementInsurance or medical plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident I0..1BackboneElementDetails of an accident
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (required)
.... location[x] 0..1Address, Reference(Location)Accident Place
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item SI1..1BackboneElementGoods and Services
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... location[x] 0..1CodeableConcept, Address, Reference(Location)Place of service
Binding: Example Service Place Codes (example)
.... quantity S0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Binding: Oral Site Codes (example)
.... subSite 0..*CodeableConceptService Sub-location
Binding: Surface Codes (example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication I0..*BackboneElementAdjudication details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required)
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Detail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... sequence 1..1positiveIntService instance
...... type 1..1CodeableConceptType of product or service
Binding: ActInvoiceGroupCode (required)
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
...... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
...... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Language if different from the resource
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
.... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Added items adjudication
.... detail I0..*BackboneElementAdded items details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Added items detail adjudication
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment I0..1BackboneElementPayment (if paid)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptPartial or Complete
Binding: Example Payment Type Codes (example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Binding: Payment Adjustment Reason Codes (example)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... form 0..1CodeableConceptPrinted Form Identifier
Binding: Form Codes (example)
... processNote I0..*BackboneElementProcessing notes
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... number 0..1positiveIntSequence number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
Binding: NoteType (required)
.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage if different from the resource
Binding: Common Languages (extensible)
... benefitBalance I0..*BackboneElementBalance by Benefit Category
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... category 1..1CodeableConceptType of services covered
Binding: Benefit Category Codes (example)
.... subCategory 0..1CodeableConceptDetailed services covered within the type
Binding: Benefit SubCategory Codes (example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: Network Type Codes (example)
.... unit 0..1CodeableConceptIndividual or family
Binding: Unit Type Codes (example)
.... term 0..1CodeableConceptAnnual or lifetime
Binding: Benefit Term Codes (example)
.... financial I0..*BackboneElementBenefit Summary
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... type 1..1CodeableConceptDeductable, visits, benefit amount
Binding: Benefit Type Codes (example)
..... allowed[x] 0..1unsignedInt, string, MoneyBenefits allowed
..... used[x] 0..1unsignedInt, MoneyBenefits used

doco Documentation for this format

This structure is derived from the STU3 FHIR® resource Explanation of Benefit.

This profile introduces the following variations from the above core resource:

  1. Conditional invariants
    • inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
    • inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
    • inv-dh-eob-03: One of subType or item.category SHALL be present.
    • inv-dh-eob-04: A PBS claim (subType=’pbs’) SHALL be of type ‘Pharmacy’ (type=’pharmacy’).
  2. One meta.profile is ‘http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare’
  3. Exactly one identifier
  4. status is ‘active’
  5. subType required binding to Australian Medicare Benefit and Claim Category value set
  6. Exactly one patient
  7. patient as AU Base Patient
  8. Exactly one created
  9. insurer as AU Base Organisation
  10. provider as AU Base Practitioner
  11. organization as AU Base Organisation
  12. referral contained as Referral Request Medicare Benefits Schedule Department of Veterans’ Affairs
  13. prescription contained as Medication Request Pharmaceutical Benefits Scheme
  14. Exactly one item
  15. item.sequence is ‘1’
  16. item.category extensible binding to Australian Medicare Benefit and Claim Category value set
  17. Exactly one item.service
  18. item.service required binding to Australian Department of Human Services Modifications of Pharmaceutical Benefits Scheme Schedule Item, Medicare Benefits Schedule Item and Department of Veterans’ Affairs Fee Schedule Item value set
  19. Exactly one item.serviced

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim (subType='pbs') SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... meta 1..1Meta
.... profile 1..*uri
... identifier S1..1Identifier
... status S0..1codeFixed Value: active
... type S0..1CodeableConcept
... subType S0..*CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)
... created S1..1dateTime
... insurer 0..1Reference(AU Base Organisation)
... provider S0..1Reference(AU Base Practitioner)
... organization 0..1Reference(AU Base Organisation)
... referral S0..1Reference(ReferralRequestMedicareBenefitsScheduleDepartmentofVeterans'Affairs) {c}
... prescription S0..1Reference(MedicationRequestPharmaceuticalBenefitsScheme) {c}
... item S1..1BackboneElement
.... sequence S1..1positiveIntFixed Value: 1
.... category S0..1CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBinding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... serviced[x] S1..1date, Period
.... quantity S0..1SimpleQuantity

doco Documentation for this format

Snapshot View

<
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*Explanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim (subType='pbs') SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... id Σ0..1idLogical id of this artifact
... meta Σ1..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ1..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: Common Tags (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier
... status ?!SΣ0..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
Fixed Value: active
... type S0..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created S1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... referral S0..1Reference(ReferralRequestMedicareBenefitsScheduleDepartmentofVeterans'Affairs) {c}Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Binding: Claim Processing Codes (example)
... disposition 0..1stringDisposition Message
... related I0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: Example Related Claim Relationship Codes (example)
.... reference 0..1IdentifierRelated file or case reference
... prescription S0..1Reference(MedicationRequestPharmaceuticalBenefitsScheme) {c}Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee I0..1BackboneElementParty to be paid any benefits payable
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Binding: Claim Payee Type Codes (example)
.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
Binding: PayeeResourceType (required)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... information I0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
.... code 0..1CodeableConceptType of information
Binding: Exception Codes (example)
.... timing[x] 0..1date, PeriodWhen it occurred
.... value[x] 0..1string, Quantity, Attachment, Reference(Resource)Additional Data or supporting information
.... reason 0..1CodingReason associated with the information
Binding: Missing Tooth Reason Codes (example)
... careTeam I0..*BackboneElementCare Team members
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Binding: Example Provider Qualification Codes (example)
... diagnosis I0..*BackboneElementList of Diagnosis
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1CodeableConcept, Reference(Condition)Patient's diagnosis
Binding: ICD-10 Codes (example)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example)
.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example)
... procedure I0..*BackboneElementProcedures performed
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1CodeableConcept, Reference(Procedure)Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance I0..1BackboneElementInsurance or medical plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident I0..1BackboneElementDetails of an accident
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (required)
.... location[x] 0..1Address, Reference(Location)Accident Place
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item SI1..1BackboneElementGoods and Services
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... location[x] 0..1CodeableConcept, Address, Reference(Location)Place of service
Binding: Example Service Place Codes (example)
.... quantity S0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Binding: Oral Site Codes (example)
.... subSite 0..*CodeableConceptService Sub-location
Binding: Surface Codes (example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication I0..*BackboneElementAdjudication details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required)
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Detail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... sequence 1..1positiveIntService instance
...... type 1..1CodeableConceptType of product or service
Binding: ActInvoiceGroupCode (required)
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
...... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
...... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Language if different from the resource
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
.... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Added items adjudication
.... detail I0..*BackboneElementAdded items details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example)
..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*