| Australian Digital Health Agency FHIR Implementation Guide 1.1.0

This page is part of the Australian Digital Health Agency FHIR Implementation Guide 1.1.0. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available previous versions.

#### StructureDefinition: ADHA Record of Claim against MBS or DVA - Detailed Descriptions

Definitions for the dh-explanationofbenefit-medicare-mbs-1 Profile.

1. ExplanationOfBenefit
Definition | A record of the claim of an item claimed against the Medicare Benefits Schedule (MBS) or Department of Veterans' Affairs (DVA). Claim items include information about healthcare services provided to an individual that were partially or fully funded by the Australian Government run benefits scheme.
Control | 0..*
Alternate Names | EOB
2. ExplanationOfBenefit.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Control | 0..1
Type | id
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
3. ExplanationOfBenefit.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Control | 0..1
Type | Meta
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. ExplanationOfBenefit.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Control | 0..1
Type | uri
Is Modifier | true
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. ExplanationOfBenefit.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages A human language
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. ExplanationOfBenefit.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1
Type | Narrative
Alternate Names | narrativehtmlxhtmldisplay
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. ExplanationOfBenefit.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Control | 0..*
Type | Resource
Alternate Names | inline resourcesanonymous resourcescontained resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
8. ExplanationOfBenefit.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. ExplanationOfBenefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. ExplanationOfBenefit.identifier
Definition | A unique identifier assigned to this explanation of benefit.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
Must Support | true
Requirements | Allows EOBs to be distinguished and referenced.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. ExplanationOfBenefit.status
Definition | The status of the resource instance.
Control | 1..1
Binding | The codes SHALL be taken from ExplanationOfBenefitStatus A code specifying the state of the resource instance
Type | code
Is Modifier | true
Must Support | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Fixed Value | active
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. ExplanationOfBenefit.type
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
Control | 1..1
Binding | The codes SHALL be taken from ClaimTypeCodes
Type | CodeableConcept
Must Support | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. ExplanationOfBenefit.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Control | 1..1
Binding | The codes SHALL be taken from https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
Type | CodeableConcept
Must Support | true
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. ExplanationOfBenefit.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Control | 1..1
Binding | The codes SHALL be taken from Use Complete, proposed, exploratory, other
Type | code
Must Support | true
Requirements | This element is required to understand the nature of the request for adjudication.
Fixed Value | claim
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. ExplanationOfBenefit.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.
Control | 1..1 This element is affected by the following invariants: inv-dh-eob-01
Type | Reference(ADHAPatientCore))
Must Support | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) inv-dh-eob-01: At least reference or a valid identifier shall be present (: reference.exists() or identifier.where(system.count() + value.count() >1).exists())
16. ExplanationOfBenefit.billablePeriod
Definition | The period for which charges are being submitted.
Control | 0..1
Type | Period
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. ExplanationOfBenefit.created
Definition | The date this resource was created.
Control | 1..1 This element is affected by the following invariants: inv-dh-eob-03
Type | dateTime
Must Support | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Comments | This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) inv-dh-eob-03: Date shall be at least to day (: toString().length() >= 10)
18. ExplanationOfBenefit.enterer
Definition | Individual who created the claim, predetermination or preauthorization.
Control | 0..1
Type | Reference(Practitioner PractitionerRole))
Requirements | Some jurisdictions require the contact information for personnel completing claims.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. ExplanationOfBenefit.insurer
Definition | The party responsible for authorization, adjudication and reimbursement.
Control | 1..1 This element is affected by the following invariants: inv-dh-eob-02
Type | Reference(ADHAOrganizationCore))
Must Support | true
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Comments | In the context of a claim against the Medicare Benefits Schedule (MBS) or Department of Veterans' Affairs (DVA), the insurer is the Australian Government Department of Health.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) inv-dh-eob-02: At least reference or a valid identifier shall be present (: reference.exists() or identifier.where(system.count() + value.count() >1).exists())
20. ExplanationOfBenefit.provider
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Control | 1..1
Type | Reference(ADHAPractitionerRoleCore))
Must Support | true
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. ExplanationOfBenefit.priority
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
Control | 0..1
Binding | For example codes, see ProcessPriorityCodes
Type | CodeableConcept
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. ExplanationOfBenefit.fundsReserveRequested
Definition | A code to indicate whether and for whom funds are to be reserved for future claims.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None)
Type | CodeableConcept
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.
Alternate Names | Fund pre-allocation
Comments | This field is only used for preauthorizations.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. ExplanationOfBenefit.fundsReserve
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None)
Type | CodeableConcept
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. ExplanationOfBenefit.related
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
Control | 0..*
Type | BackboneElement
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Comments | For example, for the original treatment and follow-up exams.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. ExplanationOfBenefit.related.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
26. ExplanationOfBenefit.related.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
27. ExplanationOfBenefit.related.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. ExplanationOfBenefit.related.claim
Definition | Reference to a related claim.
Control | 0..1
Type | Reference(Claim))
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. ExplanationOfBenefit.related.relationship
Definition | A code to convey how the claims are related.
Control | 0..1
Binding | For example codes, see ExampleRelatedClaimRelationshipCodes Relationship of this claim to a related Claim
Type | CodeableConcept
Requirements | Some insurers need a declaration of the type of relationship.
Comments | For example, prior claim or umbrella.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. ExplanationOfBenefit.related.reference
Definition | An alternate organizational reference to the case or file to which this particular claim pertains.
Control | 0..1
Type | Identifier
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. ExplanationOfBenefit.prescription
Definition | Prescription to support the dispensing of pharmacy, device or vision products.
Control | 0..1
Type | Reference(MedicationRequest VisionPrescription))
Requirements | Required to authorize the dispensing of controlled substances and devices.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. ExplanationOfBenefit.originalPrescription
Definition | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
Control | 0..1
Type | Reference(MedicationRequest))
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
Comments | For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. ExplanationOfBenefit.payee
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy.
Control | 0..1
Type | BackboneElement
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. ExplanationOfBenefit.payee.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
35. ExplanationOfBenefit.payee.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
36. ExplanationOfBenefit.payee.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
37. ExplanationOfBenefit.payee.type
Definition | Type of Party to be reimbursed: Subscriber, provider, other.
Control | 0..1
Binding | For example codes, see Claim Payee Type Codes A code for the party to be reimbursed
Type | CodeableConcept
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. ExplanationOfBenefit.payee.party
Definition | Reference to the individual or organization to whom any payment will be made.
Control | 0..1
Type | Reference(Practitioner PractitionerRole Organization Patient RelatedPerson))
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
Comments | Not required if the payee is 'subscriber' or 'provider'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. ExplanationOfBenefit.referral
Definition | A reference to a referral resource.
Control | 0..1
Type | Reference(ServiceRequest))
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services.
Comments | The referral resource which lists the date, practitioner, reason and other supporting information.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. ExplanationOfBenefit.facility
Definition | Facility where the services were provided.
Control | 0..1
Type | Reference(Location))
Requirements | Insurance adjudication can be dependant on where services were delivered.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. ExplanationOfBenefit.claim
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
Control | 0..1
Type | Reference(Claim))
Requirements | To provide a link to the original adjudication request.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.claimResponse
Definition | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.
Control | 0..1
Type | Reference(ClaimResponse))
Requirements | To provide a link to the original adjudication response.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
43. ExplanationOfBenefit.outcome
Definition | The outcome of the claim, predetermination, or preauthorization processing.
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes The result of the claim processing
Type | code
Must Support | true
Requirements | To advise the requestor of an overall processing outcome.
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Fixed Value | complete
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. ExplanationOfBenefit.disposition
Definition | A human readable description of the status of the adjudication.
Control | 0..1
Type | string
Requirements | Provided for user display.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. ExplanationOfBenefit.preAuthRef
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication.
Control | 0..*
Type | string
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Comments | This value is only present on preauthorization adjudications.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.preAuthRefPeriod
Definition | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.
Control | 0..*
Type | Period
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Comments | This value is only present on preauthorization adjudications.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. ExplanationOfBenefit.careTeam
Definition | The members of the team who provided the products and services.
Control | 0..*
Type | BackboneElement
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. ExplanationOfBenefit.careTeam.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
49. ExplanationOfBenefit.careTeam.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
50. ExplanationOfBenefit.careTeam.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
51. ExplanationOfBenefit.careTeam.sequence
Definition | A number to uniquely identify care team entries.
Control | 1..1
Type | positiveInt
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
52. ExplanationOfBenefit.careTeam.provider
Definition | Member of the team who provided the product or service.
Control | 1..1
Type | Reference(Practitioner PractitionerRole Organization))
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
53. ExplanationOfBenefit.careTeam.responsible
Definition | The party who is billing and/or responsible for the claimed products or services.
Control | 0..1
Type | boolean
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Comments | Responsible might not be required when there is only a single provider listed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. ExplanationOfBenefit.careTeam.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Control | 0..1
Binding | For example codes, see ClaimCareTeamRoleCodes The role codes for the care team members
Type | CodeableConcept
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Comments | Role might not be required when there is only a single provider listed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. ExplanationOfBenefit.careTeam.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Control | 0..1
Binding | For example codes, see ExampleProviderQualificationCodes Provider professional qualifications
Type | CodeableConcept
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
56. ExplanationOfBenefit.supportingInfo
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Control | 0..*
Type | BackboneElement
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Comments | Often there are multiple jurisdiction specific valuesets which are required.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
57. ExplanationOfBenefit.supportingInfo.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
58. ExplanationOfBenefit.supportingInfo.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
59. ExplanationOfBenefit.supportingInfo.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
60. ExplanationOfBenefit.supportingInfo.sequence
Definition | A number to uniquely identify supporting information entries.
Control | 1..1
Type | positiveInt
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
61. ExplanationOfBenefit.supportingInfo.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Control | 1..1
Binding | For example codes, see ClaimInformationCategoryCodes The valuset used for additional information category codes
Type | CodeableConcept
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Comments | This may contain a category for the local bill type codes.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. ExplanationOfBenefit.supportingInfo.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Control | 0..1
Binding | For example codes, see ExceptionCodes The valuset used for additional information codes
Type | CodeableConcept
Requirements | Required to identify the kind of additional information.
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
63. ExplanationOfBenefit.supportingInfo.timing[x]
Definition | The date when or period to which this information refers.
Control | 0..1
Type | Choice of: date, Period
[x] Note | See Choice of Data Types for further information about how to use [x]
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
64. ExplanationOfBenefit.supportingInfo.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Control | 0..1
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
65. ExplanationOfBenefit.supportingInfo.reason
Definition | Provides the reason in the situation where a reason code is required in addition to the content.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes Reason codes for the missing teeth
Type | Coding
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
66. ExplanationOfBenefit.diagnosis
Definition | Information about diagnoses relevant to the claim items.
Control | 0..*
Type | BackboneElement
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
67. ExplanationOfBenefit.diagnosis.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
68. ExplanationOfBenefit.diagnosis.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
69. ExplanationOfBenefit.diagnosis.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
70. ExplanationOfBenefit.diagnosis.sequence
Definition | A number to uniquely identify diagnosis entries.
Control | 1..1
Type | positiveInt
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
71. ExplanationOfBenefit.diagnosis.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Control | 1..1
Binding | For example codes, see ICD-10Codes ICD10 Diagnostic codes
Type | Choice of: CodeableConcept, Reference(Condition))
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
72. ExplanationOfBenefit.diagnosis.type
Definition | When the condition was observed or the relative ranking.
Control | 0..*
Binding | For example codes, see ExampleDiagnosisTypeCodes The type of the diagnosis: admitting, principal, discharge
Type | CodeableConcept
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Comments | For example: admitting, primary, secondary, discharge.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
73. ExplanationOfBenefit.diagnosis.onAdmission
Definition | Indication of whether the diagnosis was present on admission to a facility.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes Present on admission
Type | CodeableConcept
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
74. ExplanationOfBenefit.diagnosis.packageCode
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes The DRG codes associated with the diagnosis
Type | CodeableConcept
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Comments | For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
75. ExplanationOfBenefit.procedure
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Control | 0..*
Type | BackboneElement
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
76. ExplanationOfBenefit.procedure.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
77. ExplanationOfBenefit.procedure.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
78. ExplanationOfBenefit.procedure.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
79. ExplanationOfBenefit.procedure.sequence
Definition | A number to uniquely identify procedure entries.
Control | 1..1
Type | positiveInt
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
80. ExplanationOfBenefit.procedure.type
Definition | When the condition was observed or the relative ranking.
Control | 0..*
Binding | For example codes, see ExampleProcedureTypeCodes Example procedure type codes
Type | CodeableConcept
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
81. ExplanationOfBenefit.procedure.date
Definition | Date and optionally time the procedure was performed.
Control | 0..1
Type | dateTime
Requirements | Required for auditing purposes.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
82. ExplanationOfBenefit.procedure.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Control | 1..1
Binding | For example codes, see ICD-10ProcedureCodes ICD10 Procedure codes
Type | Choice of: CodeableConcept, Reference(Procedure))
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | This identifies the actual clinical procedure.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
83. ExplanationOfBenefit.procedure.udi
Definition | Unique Device Identifiers associated with this line item.
Control | 0..*
Type | Reference(Device))
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
84. ExplanationOfBenefit.precedence
Definition | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.
Control | 0..1
Type | positiveInt
Requirements | Needed to coordinate between multiple EOBs for the same suite of services.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
85. ExplanationOfBenefit.insurance
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim.
Control | 1..1
Type | BackboneElement
Must Support | true
Requirements | At least one insurer is required for a claim to be a claim.
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
86. ExplanationOfBenefit.insurance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
87. ExplanationOfBenefit.insurance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
88. ExplanationOfBenefit.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
89. ExplanationOfBenefit.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Control | 1..1
Type | boolean
Must Support | true
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
Fixed Value | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
90. ExplanationOfBenefit.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Control | 1..1
Type | Reference(Coverage))
Must Support | true
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Comments | Medicare or veteran card information may not be available in some records, for example if this resource describes claim information that was originally in another format.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
91. ExplanationOfBenefit.insurance.preAuthRef
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
Control | 0..*
Type | string
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
92. ExplanationOfBenefit.accident
Definition | Details of a accident which resulted in injuries which required the products and services listed in the claim.
Control | 0..1
Type | BackboneElement
Requirements | When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
93. ExplanationOfBenefit.accident.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
94. ExplanationOfBenefit.accident.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
95. ExplanationOfBenefit.accident.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
96. ExplanationOfBenefit.accident.date
Definition | Date of an accident event related to the products and services contained in the claim.
Control | 0..1
Type | date
Requirements | Required for audit purposes and adjudication.
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
97. ExplanationOfBenefit.accident.type
Definition | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Control | 0..1
Binding | The codes SHALL be taken from ActIncidentCode; other codes may be used where these codes are not suitable Type of accident: work place, auto, etc
Type | CodeableConcept
Requirements | Coverage may be dependant on the type of accident.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
98. ExplanationOfBenefit.accident.location[x]
Definition | The physical location of the accident event.
Control | 0..1
Type | Choice of: Address, Reference(Location))
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Required for audit purposes and determination of applicable insurance liability.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
99. ExplanationOfBenefit.item
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Control | 1..1
Type | BackboneElement
Must Support | true
Requirements | The items to be processed for adjudication.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
100. ExplanationOfBenefit.item.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
101. ExplanationOfBenefit.item.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
102. ExplanationOfBenefit.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
103. ExplanationOfBenefit.item.sequence
Definition | A number to uniquely identify item entries.
Control | 1..1
Type | positiveInt
Must Support | true
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Fixed Value | 1
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
104. ExplanationOfBenefit.item.careTeamSequence
Definition | Care team members related to this service or product.
Control | 0..*
Type | positiveInt
Requirements | Need to identify the individuals and their roles in the provision of the product or service.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
105. ExplanationOfBenefit.item.diagnosisSequence
Definition | Diagnoses applicable for this service or product.
Control | 0..*
Type | positiveInt
Requirements | Need to related the product or service to the associated diagnoses.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
106. ExplanationOfBenefit.item.procedureSequence
Definition | Procedures applicable for this service or product.
Control | 0..*
Type | positiveInt
Requirements | Need to provide any listed specific procedures to support the product or service being claimed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
107. ExplanationOfBenefit.item.informationSequence
Definition | Exceptions, special conditions and supporting information applicable for this service or product.
Control | 0..*
Type | positiveInt
Requirements | Need to reference the supporting information items that relate directly to this product or service.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
108. ExplanationOfBenefit.item.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products
Type | CodeableConcept
Requirements | Needed in the processing of institutional claims.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
109. ExplanationOfBenefit.item.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Control | 1..1
Binding | The codes SHALL be taken from https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1; other codes may be used where these codes are not suitable
Type | CodeableConcept
Must Support | true
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
110. ExplanationOfBenefit.item.productOrService
Definition | The billing code the service was claimed with against the Australian Department of Health Modifications of MBS Item and DVA Fee Schedule Item (urn:oid:1.2.36.1.2001.1005.21).
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Must Support | true
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | The code as instantiated may be padded with leading zeros when compared with the original (as published by the Department of Health).
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="urn:oid:1.2.36.1.2001.1005.21"/> </coding> </valueCodeableConcept>
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
111. ExplanationOfBenefit.item.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
112. ExplanationOfBenefit.item.programCode
Definition | Identifies the program under which this may be recovered.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes Program specific reason codes
Type | CodeableConcept
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
113. ExplanationOfBenefit.item.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Control | 1..1
Type | Choice of: date, Period
[x] Note | See Choice of Data Types for further information about how to use [x]
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
114. ExplanationOfBenefit.item.location[x]
Definition | When instantiated this element indicates the service was provided in a hospital
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes Place where the service is rendered
Type | CodeableConcept
[x] Note | See Choice of Data Types for further information about how to use [x]
Must Support | true
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Comments | When instantiated as a service in-hospital indicator this concept is equivalent to Australian Institute of Health and Welfare data element 604401 Service event—Medicare in-hospital treatment indicator, yes/no code A.
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/> <code value="HOSP"/> </coding> </valueCodeableConcept>
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
115. ExplanationOfBenefit.item.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Must Support | true
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
116. ExplanationOfBenefit.item.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
117. ExplanationOfBenefit.item.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
118. ExplanationOfBenefit.item.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
119. ExplanationOfBenefit.item.udi
Definition | Unique Device Identifiers associated with this line item.
Control | 0..*
Type | Reference(Device))
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
120. ExplanationOfBenefit.item.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Control | 0..1
Binding | For example codes, see OralSiteCodes The code for the teeth, quadrant, sextant and arch
Type | CodeableConcept
Requirements | Allows insurer to validate specific procedures.
Comments | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
121. ExplanationOfBenefit.item.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Control | 0..*
Binding | For example codes, see SurfaceCodes The code for the tooth surface and surface combinations
Type | CodeableConcept
Requirements | Allows insurer to validate specific procedures.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
122. ExplanationOfBenefit.item.encounter
Definition | A billed item may include goods or services provided in multiple encounters.
Control | 0..*
Type | Reference(Encounter))
Requirements | Used in some jurisdictions to link clinical events to claim items.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
123. ExplanationOfBenefit.item.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
124. ExplanationOfBenefit.item.adjudication
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Control | 0..*
Type | BackboneElement
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
125. ExplanationOfBenefit.item.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
126. ExplanationOfBenefit.item.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
127. ExplanationOfBenefit.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
128. ExplanationOfBenefit.item.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Control | 1..1
Binding | For example codes, see AdjudicationValueCodes The adjudication codes
Type | CodeableConcept
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
129. ExplanationOfBenefit.item.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes Adjudication reason codes
Type | CodeableConcept
Requirements | To support understanding of variance from adjudication expectations.
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
130. ExplanationOfBenefit.item.adjudication.amount
Definition | Monetary amount associated with the category.
Control | 0..1
Type | Money
Requirements | Most adjuciation categories convey a monetary amount.
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
131. ExplanationOfBenefit.item.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Control | 0..1
Type | decimal
Requirements | Some adjudication categories convey a percentage or a fixed value.
Comments | For example: eligible percentage or co-payment percentage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
132. ExplanationOfBenefit.item.detail
Definition | Second-tier of goods and services.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
133. ExplanationOfBenefit.item.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
134. ExplanationOfBenefit.item.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
135. ExplanationOfBenefit.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
136. ExplanationOfBenefit.item.detail.sequence
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Control | 1..1
Type | positiveInt
Requirements | The items to be processed for adjudication.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
137. ExplanationOfBenefit.item.detail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products
Type | CodeableConcept
Requirements | Needed in the processing of institutional claims.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
138. ExplanationOfBenefit.item.detail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes Benefit categories such as: oral, medical, vision, oral-basic etc
Type | CodeableConcept
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Comments | Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
139. ExplanationOfBenefit.item.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
140. ExplanationOfBenefit.item.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
141. ExplanationOfBenefit.item.detail.programCode
Definition | Identifies the program under which this may be recovered.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes Program specific reason codes
Type | CodeableConcept
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
142. ExplanationOfBenefit.item.detail.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
143. ExplanationOfBenefit.item.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
144. ExplanationOfBenefit.item.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
145. ExplanationOfBenefit.item.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
146. ExplanationOfBenefit.item.detail.udi
Definition | Unique Device Identifiers associated with this line item.
Control | 0..*
Type | Reference(Device))
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
147. ExplanationOfBenefit.item.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
148. ExplanationOfBenefit.item.detail.adjudication
Definition | The adjudication results.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
149. ExplanationOfBenefit.item.detail.subDetail
Definition | Third-tier of goods and services.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
150. ExplanationOfBenefit.item.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
151. ExplanationOfBenefit.item.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
152. ExplanationOfBenefit.item.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
153. ExplanationOfBenefit.item.detail.subDetail.sequence
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Control | 1..1
Type | positiveInt
Requirements | The items to be processed for adjudication.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
154. ExplanationOfBenefit.item.detail.subDetail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products
Type | CodeableConcept
Requirements | Needed in the processing of institutional claims.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
155. ExplanationOfBenefit.item.detail.subDetail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes Benefit categories such as: oral, medical, vision, oral-basic etc
Type | CodeableConcept
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
156. ExplanationOfBenefit.item.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
157. ExplanationOfBenefit.item.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
158. ExplanationOfBenefit.item.detail.subDetail.programCode
Definition | Identifies the program under which this may be recovered.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes Program specific reason codes
Type | CodeableConcept
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
159. ExplanationOfBenefit.item.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
160. ExplanationOfBenefit.item.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
161. ExplanationOfBenefit.item.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
162. ExplanationOfBenefit.item.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
163. ExplanationOfBenefit.item.detail.subDetail.udi
Definition | Unique Device Identifiers associated with this line item.
Control | 0..*
Type | Reference(Device))
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
164. ExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
165. ExplanationOfBenefit.item.detail.subDetail.adjudication
Definition | The adjudication results.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
166. ExplanationOfBenefit.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Control | 0..*
Type | BackboneElement
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
167. ExplanationOfBenefit.addItem.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
168. ExplanationOfBenefit.addItem.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
169. ExplanationOfBenefit.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
170. ExplanationOfBenefit.addItem.itemSequence
Definition | Claim items which this service line is intended to replace.
Control | 0..*
Type | positiveInt
Requirements | Provides references to the claim items.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
171. ExplanationOfBenefit.addItem.detailSequence
Definition | The sequence number of the details within the claim item which this line is intended to replace.
Control | 0..*
Type | positiveInt
Requirements | Provides references to the claim details within the claim item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
172. ExplanationOfBenefit.addItem.subDetailSequence
Definition | The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
Control | 0..*
Type | positiveInt
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
173. ExplanationOfBenefit.addItem.provider
Definition | The providers who are authorized for the services rendered to the patient.
Control | 0..*
Type | Reference(Practitioner PractitionerRole Organization))
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
174. ExplanationOfBenefit.addItem.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
175. ExplanationOfBenefit.addItem.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
176. ExplanationOfBenefit.addItem.programCode
Definition | Identifies the program under which this may be recovered.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes Program specific reason codes
Type | CodeableConcept
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
177. ExplanationOfBenefit.addItem.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Control | 0..1
Type | Choice of: date, Period
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
178. ExplanationOfBenefit.addItem.location[x]
Definition | Where the product or service was provided.
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes Place where the service is rendered
Type | Choice of: CodeableConcept, Address, Reference(Location))
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
179. ExplanationOfBenefit.addItem.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
180. ExplanationOfBenefit.addItem.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
181. ExplanationOfBenefit.addItem.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
182. ExplanationOfBenefit.addItem.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
183. ExplanationOfBenefit.addItem.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Control | 0..1
Binding | For example codes, see OralSiteCodes The code for the teeth, quadrant, sextant and arch
Type | CodeableConcept
Requirements | Allows insurer to validate specific procedures.
Comments | For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
184. ExplanationOfBenefit.addItem.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Control | 0..*
Binding | For example codes, see SurfaceCodes The code for the tooth surface and surface combinations
Type | CodeableConcept
Requirements | Allows insurer to validate specific procedures.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
185. ExplanationOfBenefit.addItem.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
186. ExplanationOfBenefit.addItem.adjudication
Definition | The adjudication results.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
187. ExplanationOfBenefit.addItem.detail
Definition | The second-tier service adjudications for payor added services.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
188. ExplanationOfBenefit.addItem.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
189. ExplanationOfBenefit.addItem.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
190. ExplanationOfBenefit.addItem.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
191. ExplanationOfBenefit.addItem.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
192. ExplanationOfBenefit.addItem.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
193. ExplanationOfBenefit.addItem.detail.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
194. ExplanationOfBenefit.addItem.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
195. ExplanationOfBenefit.addItem.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
196. ExplanationOfBenefit.addItem.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
197. ExplanationOfBenefit.addItem.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
198. ExplanationOfBenefit.addItem.detail.adjudication
Definition | The adjudication results.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
199. ExplanationOfBenefit.addItem.detail.subDetail
Definition | The third-tier service adjudications for payor added services.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
200. ExplanationOfBenefit.addItem.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
201. ExplanationOfBenefit.addItem.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
202. ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
203. ExplanationOfBenefit.addItem.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Control | 1..1
Binding | For example codes, see USCLSCodes Allowable service and product codes
Type | CodeableConcept
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug CodeBill CodeService Code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
204. ExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
Type | CodeableConcept
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
205. ExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Control | 0..1
Type | Quantity(SimpleQuantity)
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
206. ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Control | 0..1
Type | Money
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
207. ExplanationOfBenefit.addItem.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Control | 0..1
Type | decimal
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
208. ExplanationOfBenefit.addItem.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Control | 0..1
Type | Money
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
209. ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Control | 0..*
Type | positiveInt
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
210. ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition | The adjudication results.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
211. ExplanationOfBenefit.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Control | 0..*
Type | See ttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
212. ExplanationOfBenefit.total
Definition | Categorized monetary totals for the adjudication.
Control | 0..*
Type | BackboneElement
Requirements | To provide the requestor with financial totals by category for the adjudication.
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
213. ExplanationOfBenefit.total.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
214. ExplanationOfBenefit.total.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
215. ExplanationOfBenefit.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
216. ExplanationOfBenefit.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Control | 1..1
Binding | For example codes, see AdjudicationValueCodes The adjudication codes
Type | CodeableConcept
Requirements | Needed to convey the type of total provided.
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
217. ExplanationOfBenefit.total.amount
Definition | Monetary total amount associated with the category.
Control | 1..1
Type | Money
Requirements | Needed to convey the total monetary amount.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
218. ExplanationOfBenefit.payment
Definition | Payment details for the adjudication of the claim.
Control | 0..1
Type | BackboneElement
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
219. ExplanationOfBenefit.payment.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
220. ExplanationOfBenefit.payment.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
221. ExplanationOfBenefit.payment.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
222. ExplanationOfBenefit.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Control | 0..1
Binding | For example codes, see ExamplePaymentTypeCodes The type (partial, complete) of the payment
Type | CodeableConcept
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
223. ExplanationOfBenefit.payment.adjustment
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Control | 0..1
Type | Money
Requirements | To advise the requestor of adjustments applied to the payment.
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
224. ExplanationOfBenefit.payment.adjustmentReason
Definition | Reason for the payment adjustment.
Control | 0..1
Binding | For example codes, see PaymentAdjustmentReasonCodes Payment Adjustment reason codes
Type | CodeableConcept
Requirements | Needed to clarify the monetary adjustment.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
225. ExplanationOfBenefit.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Control | 0..1
Type | date
Requirements | To advise the payee when payment can be expected.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
226. ExplanationOfBenefit.payment.amount
Definition | Benefits payable less any payment adjustment.
Control | 0..1
Type | Money
Requirements | Needed to provide the actual payment amount.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
227. ExplanationOfBenefit.payment.identifier
Definition | Issuer's unique identifier for the payment instrument.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Requirements | Enable the receiver to reconcile when payment received.
Comments | For example: EFT number or check number.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
228. ExplanationOfBenefit.formCode
Definition | A code for the form to be used for printing the content.
Control | 0..1
Binding | For example codes, see Form Codes The forms codes
Type | CodeableConcept
Requirements | Needed to specify the specific form used for producing output for this response.
Comments | May be needed to identify specific jurisdictional forms.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
229. ExplanationOfBenefit.form
Definition | The actual form, by reference or inclusion, for printing the content or an EOB.
Control | 0..1
Type | Attachment
Requirements | Needed to include the specific form used for producing output for this response.
Comments | Needed to permit insurers to include the actual form.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
230. ExplanationOfBenefit.processNote
Definition | A note that describes or explains adjudication results in a human readable form.
Control | 0..*
Type | BackboneElement
Requirements | Provides the insurer specific textual explanations associated with the processing.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
231. ExplanationOfBenefit.processNote.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
232. ExplanationOfBenefit.processNote.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
233. ExplanationOfBenefit.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
234. ExplanationOfBenefit.processNote.number
Definition | A number to uniquely identify a note entry.
Control | 0..1
Type | positiveInt
Requirements | Necessary to provide a mechanism to link from adjudications.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
235. ExplanationOfBenefit.processNote.type
Definition | The business purpose of the note text.
Control | 0..1
Binding | The codes SHALL be taken from NoteType The presentation types of notes
Type | code
Requirements | To convey the expectation for when the text is used.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
236. ExplanationOfBenefit.processNote.text
Definition | The explanation or description associated with the processing.
Control | 0..1
Type | string
Requirements | Required to provide human readable explanation.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
237. ExplanationOfBenefit.processNote.language
Definition | A code to define the language used in the text of the note.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages A human language
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | CodeableConcept
Requirements | Note text may vary from the resource defined language.
Comments | Only required if the language is different from the resource language.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
238. ExplanationOfBenefit.benefitPeriod
Definition | The term of the benefits documented in this response.
Control | 0..1
Type | Period
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
Comments | Not applicable when use=claim.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
239. ExplanationOfBenefit.benefitBalance
Definition | Balance by Benefit Category.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
240. ExplanationOfBenefit.benefitBalance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
241. ExplanationOfBenefit.benefitBalance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
242. ExplanationOfBenefit.benefitBalance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
243. ExplanationOfBenefit.benefitBalance.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Control | 1..1
Binding | For example codes, see BenefitCategoryCodes Benefit categories such as: oral, medical, vision, oral-basic etc
Type | CodeableConcept
Requirements | Needed to convey the category of service or product for which eligibility is sought.
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
244. ExplanationOfBenefit.benefitBalance.excluded
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Control | 0..1
Type | boolean
Requirements | Needed to identify items that are specifically excluded from the coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
245. ExplanationOfBenefit.benefitBalance.name
Definition | A short name or tag for the benefit.
Control | 0..1
Type | string
Requirements | Required to align with other plan names.
Comments | For example: MED01, or DENT2.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
246. ExplanationOfBenefit.benefitBalance.description
Definition | A richer description of the benefit or services covered.
Control | 0..1
Type | string
Requirements | Needed for human readable reference.
Comments | For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
247. ExplanationOfBenefit.benefitBalance.network
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Control | 0..1
Binding | For example codes, see NetworkTypeCodes Code to classify in or out of network services
Type | CodeableConcept
Requirements | Needed as in or out of network providers are treated differently under the coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
248. ExplanationOfBenefit.benefitBalance.unit
Definition | Indicates if the benefits apply to an individual or to the family.
Control | 0..1
Binding | For example codes, see UnitTypeCodes Unit covered/serviced - individual or family
Type | CodeableConcept
Requirements | Needed for the understanding of the benefits.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
249. ExplanationOfBenefit.benefitBalance.term
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
Control | 0..1
Binding | For example codes, see BenefitTermCodes Coverage unit - annual, lifetime
Type | CodeableConcept
Requirements | Needed for the understanding of the benefits.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
250. ExplanationOfBenefit.benefitBalance.financial
Definition | Benefits Used to date.
Control | 0..*
Type | BackboneElement
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
251. ExplanationOfBenefit.benefitBalance.financial.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
252. ExplanationOfBenefit.benefitBalance.financial.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
253. ExplanationOfBenefit.benefitBalance.financial.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
254. ExplanationOfBenefit.benefitBalance.financial.type
Definition | Classification of benefit being provided.
Control | 1..1
Binding | For example codes, see BenefitTypeCodes Deductable, visits, co-pay, etc
Type | CodeableConcept
Requirements | Needed to convey the nature of the benefit.
Comments | For example: deductible, visits, benefit amount.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
255. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition | The quantity of the benefit which is permitted under the coverage.
Control | 0..1
Type | Choice of: unsignedInt, string, Money
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Needed to convey the benefits offered under the coverage.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
256. ExplanationOfBenefit.benefitBalance.financial.used[x]
Definition | The quantity of the benefit which have been consumed to date.
Control | 0..1
Type | Choice of: unsignedInt, Money
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Needed to convey the benefits consumed to date.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))