| 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 PBS or RPBS [Active]

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

This profile identifies the additional constraints, extensions, and value sets that build on and extend ExplanationOfBenefit that are supported.

This profile is designed to set an ExplanationOfBenefit standard for:

- Query for a record of a PBS or RPBS item claim associated with a patient
- Record or update a PBS or RPBS item claim associated with a patient

#### Profile specific guidance

- In an exchange with the My Health Record system references to a MedicationRequest resource will be contained.

#### Boundaries and relationships

This profile is not referenced by another profile in this implementation guide.

#### Formal Views of Profile Content

The official URL for this profile is:

    http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-explanationofbenefit-medicare-pbs-1

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

This profile builds on ExplanationOfBenefit.

This profile was published on 2023-08-07 09:41:43+1000 as a active by Australian Digital Health Agency.

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

- Differential Table
- Snapshot Table
- All

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

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

Differential View

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

Snapshot View

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

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ExplanationOfBenefit.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
ExplanationOfBenefit.status | required | Fixed Value: active
ExplanationOfBenefit.type | extensible | Pattern: pharmacy
ExplanationOfBenefit.subType | required | https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.use | required | Fixed Value: claim
ExplanationOfBenefit.priority | example | ProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.prescription.type | extensible | ResourceType
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codes
ExplanationOfBenefit.outcome | required | Fixed Value: complete
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodes
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codes
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes
ExplanationOfBenefit.accident.type | extensible | ActIncidentCode
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodes
ExplanationOfBenefit.item.category | extensible | https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.item.productOrService | example | Pattern: null
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySite | example | OralSiteCodes
ExplanationOfBenefit.item.subSite | example | SurfaceCodes
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodes
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes
ExplanationOfBenefit.total.category | example | AdjudicationValueCodes
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCode | example | Form Codes
ExplanationOfBenefit.processNote.type | required | NoteType
ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes
ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes

#### Search Parameters

None defined.