My Health Record FHIR IG
1.2.0 - active

My Health Record FHIR IG - Local Development build (v1.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: MHR Medical Conditions View Explanation of Benefit

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-explanationofbenefit-mcv-1 | Version: 1.2.0
Active as of 2024-09-19 | Computable Name: MHRExplanationofBenefitMCV
Copyright/Legal: Copyright © 2024 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to support an explanation of benefit for consolidated view of medical conditions and past medical history contained in a patient's My Health Record. This profile is derived from the ExplanationOfBenefit resource and identifies the data structures and obligations that must be met when conforming to this profile.

Usage:

- Refer to this Resource Profile: MHR Medical Conditions View Document Composition and MHR Medical Conditions View Provenance

### Formal Views of Profile Content

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

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

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id |  | 1..1 | id | Logical id of this artifact
status | SO | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
use | SO | 1..1 | code | claim | preauthorization | predetermination Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
created | SO | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
provider | SO | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example)
outcome |  | 1..1 | code | queued | complete | error | partial Fixed Value: complete
insurance |  | 1..1 | BackboneElement | Patient insurance information
focal |  | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
valueCode |  | 1..1 | code | Value of extension Fixed Value: unknown
item |  |  |  |
sequence | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  |  |  |
system | SO | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
code | SO | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
serviced[x] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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/v3-RoleCode
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet / Code | URI
ExplanationOfBenefit.type | required | Pattern: institutional("Institutional") `http://hl7.org/fhir/ValueSet/claim-type` from the FHIR Standard
ExplanationOfBenefit.subType | required | Pattern: mbs("MBS") `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` from the FHIR Standard
ExplanationOfBenefit.item.category | extensible | Pattern: "Medicare Benefits Schedule" `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id | Σ | 1..1 | id | Logical id of this artifact
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!SO 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
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
use | SO Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO Σ | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
created | SO Σ | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
provider | SO Σ | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example)
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
insurance | Σ | 1..1 | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information
Slices for extension |  |  |  | Content/Rules for all slices
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
Slices for value[x] |  | 1..1 | code | Value of extension Slice: Unordered, Closed by type:$this Binding: DataAbsentReason (required)
value[x]:valueCode |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: unknown
item |  | 0..* | BackboneElement | Product or service provided
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding | Σ | 0..* | Coding | Code defined by a terminology system
system | SO Σ | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
code | SO Σ | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
serviced[x] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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/v3-RoleCode
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ExplanationOfBenefit.status | required | Fixed Value: active `http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1` from the FHIR Standard
ExplanationOfBenefit.type | required | Pattern: institutional("Institutional") `http://hl7.org/fhir/ValueSet/claim-type` from the FHIR Standard
ExplanationOfBenefit.subType | required | Pattern: mbs("MBS") `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use | required | Fixed Value: claim `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` from the FHIR Standard
ExplanationOfBenefit.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` from the FHIR Standard
ExplanationOfBenefit.outcome | required | Fixed Value: complete `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` from the FHIR Standard
ExplanationOfBenefit.insurance.coverage.extension:dataAbsentReason.value[x] | required | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
ExplanationOfBenefit.insurance.coverage.extension:dataAbsentReason.value[x]:valueCode | required | Fixed Value: unknown `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
ExplanationOfBenefit.item.category | extensible | Pattern: "Medicare Benefits Schedule" `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` from the FHIR Standard
ExplanationOfBenefit.item.location[x] | example | Pattern: HOSP `http://hl7.org/fhir/ValueSet/service-place` from the FHIR Standard

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id | Σ | 1..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 |  | 0..* | Identifier | Business Identifier for the resource
status | ?!SO 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
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | SO Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO Σ | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | SO Σ | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
provider | SO Σ | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
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 | 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 | 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 | Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
Slices for value[x] |  | 1..1 | code | Value of extension Slice: Unordered, Closed by type:$this Binding: DataAbsentReason (required)
value[x]:valueCode |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: unknown
reference | Σ C | 0..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
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 |  | 0..* | 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 | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | SO Σ | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
version | Σ | 0..1 | string | Version of the system - if relevant
code | SO Σ | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 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] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
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
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
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 0..1 | Period | When the benefits are applicable
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

#### Terminology Bindings

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

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 1 element(4 nested mandatory elements)
Must-Support: 14 elements
Fixed: 7 elements

Structures

This structure refers to these other structures:

- MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
- AU Core PractitionerRole (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitionerrole)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason

Differential View

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id |  | 1..1 | id | Logical id of this artifact
status | SO | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
use | SO | 1..1 | code | claim | preauthorization | predetermination Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
created | SO | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
provider | SO | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example)
outcome |  | 1..1 | code | queued | complete | error | partial Fixed Value: complete
insurance |  | 1..1 | BackboneElement | Patient insurance information
focal |  | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
valueCode |  | 1..1 | code | Value of extension Fixed Value: unknown
item |  |  |  |
sequence | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  |  |  |
system | SO | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
code | SO | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
serviced[x] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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/v3-RoleCode
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet / Code | URI
ExplanationOfBenefit.type | required | Pattern: institutional("Institutional") `http://hl7.org/fhir/ValueSet/claim-type` from the FHIR Standard
ExplanationOfBenefit.subType | required | Pattern: mbs("MBS") `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` from the FHIR Standard
ExplanationOfBenefit.item.category | extensible | Pattern: "Medicare Benefits Schedule" `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id | Σ | 1..1 | id | Logical id of this artifact
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!SO 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
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
use | SO Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO Σ | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
created | SO Σ | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
provider | SO Σ | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example)
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Fixed Value: complete
insurance | Σ | 1..1 | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information
Slices for extension |  |  |  | Content/Rules for all slices
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
Slices for value[x] |  | 1..1 | code | Value of extension Slice: Unordered, Closed by type:$this Binding: DataAbsentReason (required)
value[x]:valueCode |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: unknown
item |  | 0..* | BackboneElement | Product or service provided
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
coding | Σ | 0..* | Coding | Code defined by a terminology system
system | SO Σ | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
code | SO Σ | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
serviced[x] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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/v3-RoleCode
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ExplanationOfBenefit.status | required | Fixed Value: active `http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1` from the FHIR Standard
ExplanationOfBenefit.type | required | Pattern: institutional("Institutional") `http://hl7.org/fhir/ValueSet/claim-type` from the FHIR Standard
ExplanationOfBenefit.subType | required | Pattern: mbs("MBS") `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.use | required | Fixed Value: claim `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` from the FHIR Standard
ExplanationOfBenefit.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` from the FHIR Standard
ExplanationOfBenefit.outcome | required | Fixed Value: complete `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` from the FHIR Standard
ExplanationOfBenefit.insurance.coverage.extension:dataAbsentReason.value[x] | required | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
ExplanationOfBenefit.insurance.coverage.extension:dataAbsentReason.value[x]:valueCode | required | Fixed Value: unknown `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
ExplanationOfBenefit.item.category | extensible | Pattern: "Medicare Benefits Schedule" `https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1` from https://tx.ontoserver.csiro.au/fhir
ExplanationOfBenefit.item.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` from the FHIR Standard
ExplanationOfBenefit.item.location[x] | example | Pattern: HOSP `http://hl7.org/fhir/ValueSet/service-place` from the FHIR Standard

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Record of Claim
id | Σ | 1..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 |  | 0..* | Identifier | Business Identifier for the resource
status | ?!SO 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
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 1..1 | string | Representation defined by the system Fixed Value: Institutional
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType | SO | 0..1 | CodeableConcept | More granular claim type Binding: Australian Medicare Benefit and Claim Category (required) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | SO Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Fixed Value: claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
patient | SO Σ | 1..1 | Reference(MHR Patient) | The recipient of the products and services
Obligations | Actor
SHALL:handle | MHR Gateway Requester
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | SO Σ | 1..1 | dateTime | Response creation date
Obligations | Actor
SHALL:handle | MHR Gateway Requester
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
provider | SO Σ | 1..1 | Reference(AU Core PractitionerRole) | Party responsible for the claim
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
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 | 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 | 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 | Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
dataAbsentReason |  | 0..* | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
Slices for value[x] |  | 1..1 | code | Value of extension Slice: Unordered, Closed by type:$this Binding: DataAbsentReason (required)
value[x]:valueCode |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: unknown
reference | Σ C | 0..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
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 |  | 0..* | 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 | SO | 1..1 | positiveInt | Item instance identifier Fixed Value: 1
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO | 1..1 | CodeableConcept | Benefit classification Binding: Australian Medicare Benefit and Claim Category (extensible) Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mbs
display |  | 1..1 | string | Representation defined by the system Fixed Value: MBS
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 1..1 | string | Plain text representation of the concept Fixed Value: Medicare Benefits Schedule
productOrService | SO | 1..1 | CodeableConcept | MBS Billing code Binding: USCLSCodes (example): Allowable service and product codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | SO Σ | 1..1 | uri | Identity of the terminology system Fixed Value: urn:oid:1.2.36.1.2001.1005.21
Obligations | Actor
SHALL:handle | MHR Gateway Requester
version | Σ | 0..1 | string | Version of the system - if relevant
code | SO Σ | 1..1 | code | Symbol in syntax defined by the system
Obligations | Actor
SHALL:handle | MHR Gateway Requester
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 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] | SO | 1..1 | date | Date or dates of service or product delivery
Obligations | Actor
SHALL:handle | MHR Gateway Requester
location[x] | SO | 0..1 | CodeableConcept | Service in-hospital indicator Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. Required Pattern: At least the following
Obligations | Actor
SHALL:handle | MHR Gateway Requester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HOSP
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
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
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 0..1 | Period | When the benefits are applicable
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

#### Terminology Bindings

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

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 1 element(4 nested mandatory elements)
Must-Support: 14 elements
Fixed: 7 elements

Structures

This structure refers to these other structures:

- MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
- AU Core PractitionerRole (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitionerrole)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason

Other representations of profile: CSV, Excel, Schematron