Name Flags Card. Type Description & Constraints ExplanationOfBenefit C 0..* ExplanationOfBenefit 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 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..1 Meta Metadata about the resource profile 1..* uri Profiles this resource claims to conform to identifier S 1..1 Identifier Business Identifier status S 0..1 code active | cancelled | draft | entered-in-error Fixed Value: active type S 0..1 CodeableConcept Type or discipline subType S 0..* CodeableConcept Finer grained claim type information Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required) patient S 1..1 Reference(AU Base Patient) The subject of the Products and Services created S 1..1 dateTime Creation date insurer 0..1 Reference(AU Base Organisation) Insurer responsible for the EOB provider S 0..1 Reference(AU Base Practitioner) Responsible provider for the claim organization 0..1 Reference(AU Base Organisation) Responsible organization for the claim referral S 0..1 Reference(ADHA MBS DVA ReferralRequest) {c} Treatment Referral prescription S 0..1 Reference(ADHA PBS MedicationRequest) {c} Prescription authorizing services or products item S 1..1 BackboneElement Goods and Services sequence S 1..1 positiveInt Service instance Fixed Value: 1 category S 0..1 CodeableConcept Type of service or product Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible) service S 1..1 CodeableConcept Billing Code Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required) serviced[x] S 1..1 date, Period Date or dates of Service quantity S 0..1 SimpleQuantity Count of Products or Services Documentation for this format
The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS), Department of Veterans’ Affairs (DVA), Pharmaceutical Benefits Schedule (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between Medicare repositories and the My Health Record system infrastructure in Australia.
Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.
Canadian Dental Association eclaims standard
This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL NOT contain any narrative
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty()
not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
A PBS or RPBS claim SHALL include a prescription.
prescription.exists() implies (subType.coding.code='pbs' or subType.coding.code='rpbs' or item.category.coding.code='pbs' or item.category.coding.code='rpbs')
A MBS or DVABS claim SHALL NOT include a prescription.
prescription.empty() implies (subType.coding.code='mbs' or subType.coding.code='dva' or item.category.coding.code='mbs' or item.category.coding.code='dva')
One of subType or item.category SHALL be present.
subType.exists() or item.category.exists()
A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy').
prescription.exists() implies type.coding.code='pharmacy'
One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional Content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
The version specific identifier, as it appears in the version portion of the URL. This values changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
A code specifying the state of the resource instance.
The category of claim, eg, oral, pharmacy, vision, insitutional, professional.
Affects which fields and value sets are used.
The type or discipline-style of the claim
A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
This may contain the local bill type codes such as the US UB-04 bill type code.
The subject of the Products and Services
The billable period for which charges are being submitted.
The person who created the explanation of benefit.
The insurer which is responsible for the explanation of benefit.
The provider which is responsible for the claim.
The referral resource which lists the date, practitioner, reason and other supporting information.
Facility where the services were provided.
The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
Processing outcome errror, partial or complete processing.
A description of the status of the adjudication.
Related Claims which may be revelant to processing this claim
Other claims which are related to this claim such as prior claim versions or for related services.
All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Relationship of this claim to a related Claim
An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .
Prescription authorizing services or products
Prescription to support the dispensing of Pharmacy or Vision products.
Original prescription if superceded by fulfiller
Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
The party to be reimbursed for the services.
Type of party: Subscriber, Provider, other
Type of Party to be reimbursed: Subscriber, provider, other.
organization | patient | practitioner | relatedperson
organization | patient | practitioner | relatedperson.
Party to be reimbursed: Subscriber, provider, other.
Exceptions, special considerations, the condition, situation, prior or concurrent issues
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Sequence of the information element which serves to provide a link.
The general class of the information supplied: information; exception; accident, employment; onset, etc.
The valuset used for additional information category codes.
System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.
The valuset used for additional information codes.
The date when or period to which this information refers.
Additional Data or supporting information
Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.
The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
Role and Responsible may not be required when there is only a single provider listed.
Sequence of careteam which serves to order and provide a link.
Required to maintain order of the careteam members.
The members of the team who provided the overall service.
The practitioner who is billing and responsible for the claimed services rendered to the patient.
The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.
The role codes for the care team members.
The qualification which is applicable for this service.
Ordered list of patient diagnosis for which care is sought.
Sequence of diagnosis which serves to provide a link.
Required to allow line items to reference the diagnoses.
Required to adjudicate services rendered to condition presented.
The type of the Diagnosis, for example: admitting, primary, secondary, discharge.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Required to adjudicate services rendered to the mandated diagnosis grouping system.
The type of the diagnosis: admitting, principal, discharge
The package billing code, for example DRG, based on the assigned grouping code system.
Required to adjudicate services rendered to the mandated grouping system.
The DRG codes associated with the diagnosis
Ordered list of patient procedures performed to support the adjudication.
Sequence of procedures which serves to order and provide a link.
Required to maintain order of the procudures.
Date and optionally time the procedure was performed .
Required to adjudicate services rendered.
Health care programs and insurers are significant payors of health service costs.
Financial instrument by which payment information for health care.
Reference to the program or plan identification, underwriter or payor.
Need to identify the issuer to target for processing and for coordination of benefit processing.
Pre-Authorization/Determination Reference
A list of references from the Insurer to which these services pertain.
To provide any pre=determination or prior authorization reference.
An accident which resulted in the need for healthcare services.
Date of an accident which these services are addressing.
Coverage may be dependant on the type of accident.
Type of accident: work place, auto, etc.
The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
The start and optional end dates of when the patient was confined to a treatment center.
Careteam applicable for this service or product line.
Diagnosis applicable for this service or product line.
Procedures applicable for this service or product line.
Applicable exception and supporting information
Exceptions, special conditions and supporting information pplicable for this service or product line.
The type of reveneu or cost center providing the product and/or service.
Codes for the revenue or cost centers supplying the service and/or products.
Health Care Service Type Codes to identify the classification of service or benefits.
If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.
Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program specific reason for item inclusion
For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.
The date or dates when the enclosed suite of services were performed or completed.
The number of repetitions of a service or product.
If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.
A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
If a fee is present the associated product/service code must be present.
The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.
List of Unique Device Identifiers associated with this line item.
The UDI code and issuer if applicable for the supplied product.
Physical service site on the patient (limb, tooth, etc).
The code for the teeth, quadrant, sextant and arch
A region or surface of the site, eg. limb region or tooth surface(s).
The code for the tooth surface and surface combinations
A billed item may include goods or services provided in multiple encounters.
A list of note references to the notes provided below.
Adjudication category such as co-pay, eligible, benefit, etc.
Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.
Adjudication reason such as limit reached.
Monitory amount associated with the code.
A non-monetary value for example a percentage. Mutually exclusive to the amount element above.
Service, Product, Rx Dispense, Rx Compound etc.
Benefit subcategories such as: oral-basic, major, glasses
A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).
The fee for an addittional service or product or charge.
The first tier service adjudications for payor added services.
List of input service items which this service line is intended to replace.
The fee charged for the professional service or product.
The second tier service adjudications for payor added services.
The total cost of the services reported.
This is a check value that the receiver calculates and returns.
The amount of deductable applied which was not allocated to any particular service line.
Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
Payment details for the claim if the claim has been paid.
Whether this represents partial or complete payment of the claim.
The type (partial, complete) of the payment
Adjustment to the payment of this transaction which is not related to adjudication of this transaction.
Explanation for the non-claim adjustment
The form to be used for printing the content.
An integer associated with each note which may be referred to from each service line item.
The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.
Dental, Vision, Medical, Pharmacy, Rehab etc.
Benefit categories such as: oral, medical, vision etc.
Detailed services covered within the type
Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.
True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.
A short name or tag for the benefit, for example MED01, or DENT2.
Description of the benefit or services covered
A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.
Code to classify in or out of network services
Unit covered/serviced - individual or family
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.