Notes on Fields

• The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
• CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total If there is a mix of lines paid in network and out of network on a claim, the value of C4BB Payer Benefit Payment Status is ‘Other’
• Add to total[inoutnetwork]:   value = other when there is a mix of in network and out of network lines on the claim
• .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indiate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
• .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
• .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
• .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
• .item.productOrService:   CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on a professional / non-clinician claim . The cardinality of the HL7 base EOB Resource for .item.revenue is 1..1 if .item is provided. Since item.productOrService is required it means that .item.revenue must be populated. Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason for item.revenue.
• item.adjudication[inoutnetwork]:  in network or out of network payment status for the line
• .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
• .item.adjudication[inoutnetwork]:  place in network or out of network payment status here
• .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
• The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from C4BBExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: professional
careTeam	I	0..*	BackboneElement	Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner EOB-prof-careTeam-organization: Professional EOB: Careteam roles refer to an organization
role		1..1	CodeableConcept	Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: US Core Provider Speciality (NUCC) (required)
supportingInfo		0..*	(Slice Definition)	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:billingnetworkcontractingstatus		0..1	BackboneElement	Supporting information
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus
code	S	1..1	CodeableConcept	Type of information Binding: C4BB Payer Provider Contracting Status (required)
supportingInfo:performingnetworkcontractingstatus		0..1	BackboneElement	Supporting information
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus
code	S	1..1	CodeableConcept	Type of information Binding: C4BB Payer Provider Contracting Status (required)
supportingInfo:clmrecvddate		0..1	BackboneElement	Supporting information
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: clmrecvddate
timing[x]	S	1..1	date	When it occurred
supportingInfo:servicefacility		0..1	BackboneElement	Supporting information
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: servicefacility
value[x]		1..1	(Slice Definition)	Data to be provided Slice: Unordered, Open by type:$this
valueReference	S	1..1	Reference(C4BB Organization)	Data to be provided
diagnosis	S	1..*	BackboneElement	Pertinent diagnosis information
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
type	S	1..1	CodeableConcept	Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
item
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Codes (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Modifier Codes (required)
serviced[x]		0..1	date, Period	Date or dates of service or product delivery
location[x]		0..1	CodeableConcept	Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required)
quantity		0..1	SimpleQuantity	Count of products or services
adjudication		1..*	(Slice Definition)	Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:adjudicationamounttype		0..*	BackboneElement	Amounts
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication (required)
amount	S	0..1	Money	Monetary amount
adjudication:denialreason		0..1	BackboneElement	Reason codes used to interpret the Non-Covered Amount (92)
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: denialreason
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:inoutnetwork		1..1	BackboneElement	Indicates the in network or out of network payment status of the claim. (142)
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required)
adjudication:allowedunits		0..1	BackboneElement	The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: allowedunits
total		1..*	(Slice Definition)	Adjudication totals Slice: Unordered, Open by pattern:category
total:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information
amount		1..1	Money	Financial total for the category
total:adjudicationamounttype		0..*	BackboneElement	Adjudication totals
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication (required)
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource
id	Σ	0..1	string	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	SΣ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible)
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example)
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) Max Binding: AllLanguages
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	Business Identifier for the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	SΣ	1..1	CodeableConcept	Description of identifier Binding: C4BB Claim Identifier Type (extensible)
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required)
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
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: professional
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example)
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim
patient	SΣ	1..1	Reference(C4BB Patient)	The recipient of the products and services
billablePeriod	SΣ	0..1	Period	Relevant time frame for the claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣI	0..1	dateTime	Starting time with inclusive boundary
end	ΣI	0..1	dateTime	End time with inclusive boundary, if not ongoing
created	Σ	1..1	dateTime	Response creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(C4BB Organization)	Party responsible for reimbursement
provider	SΣ	1..1	Reference(C4BB Organization | C4BB Practitioner)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example)
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example)
related	S	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	S	1..1	CodeableConcept	How the reference claim is related Binding: C4BB Related Claim Relationship Codes (required)
reference	S	1..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	S	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	S	1..1	CodeableConcept	Category of recipient Binding: C4BB Payee Type (required)
party	S	1..1	Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)	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	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required)
disposition		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference
preAuthRefPeriod		0..*	Period	Preauthorization in-effect period
careTeam	SI	0..*	BackboneElement	Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner EOB-prof-careTeam-organization: Professional EOB: Careteam roles refer to an organization
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	S	1..1	Reference(C4BB Organization | C4BB Practitioner)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	1..1	CodeableConcept	Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: US Core Provider Speciality (NUCC) (required)
supportingInfo	S	0..*	(Slice Definition)	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
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: C4BB SupportingInfo Type (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example)
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)
supportingInfo:billingnetworkcontractingstatus	S	0..1	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	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus
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
code	S	1..1	CodeableConcept	Type of information Binding: C4BB Payer Provider Contracting Status (required)
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)
supportingInfo:performingnetworkcontractingstatus	S	0..1	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	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus
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
code	S	1..1	CodeableConcept	Type of information Binding: C4BB Payer Provider Contracting Status (required)
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)
supportingInfo:clmrecvddate	S	0..1	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	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: clmrecvddate
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
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example)
timing[x]	S	1..1	date	When it occurred
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)
supportingInfo:servicefacility	S	0..1	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	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: servicefacility
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
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		1..1	(Slice Definition)	Data to be provided Slice: Unordered, Closed by type:$this
value[x]:valueReference	S	1..1	Reference(C4BB Organization)	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example)
diagnosis	S	1..*	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]	S	1..1	CodeableConcept	Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
type	S	1..1	CodeableConcept	Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example)
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example)
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)
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example)
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	SΣI	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	SΣ	1..1	boolean	Coverage to be used for adjudication
coverage	SΣ	1..1	Reference(C4BB Coverage)	Insurance information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible)
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item	S	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	S	1..1	positiveInt	Item instance identifier
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)
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example)
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Codes (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Modifier Codes (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1	CodeableConcept	Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required)
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)
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example)
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	(Slice Definition)	Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
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	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Amounts
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	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount	S	0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:denialreason	S	0..1	BackboneElement	Reason codes used to interpret the Non-Covered Amount (92)
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	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: denialreason
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
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:inoutnetwork	S	1..1	BackboneElement	Indicates the in network or out of network payment status of the claim. (142)
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	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:allowedunits	S	0..1	BackboneElement	The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
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	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example) Required Pattern: At least the following
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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: allowedunits
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
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
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)
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example)
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
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	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)
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example)
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
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	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)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
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)
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)
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example)
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication	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)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
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	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)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
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	Added items adjudication
adjudication	S	0..*	See adjudication	Header-level adjudication
total	SΣ	1..*	(Slice Definition)	Adjudication totals Slice: Unordered, Open by pattern:category
total:All Slices				Content/Rules for all slices
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	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example)
amount	Σ	1..1	Money	Financial total for the category
total:adjudicationamounttype	SΣ	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: C4BB Adjudication (required)
amount	Σ	1..1	Money	Financial total for the category
payment	S	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	S	0..1	CodeableConcept	Partial or complete payment Binding: C4BB Payer Claim Payment Status Code (required)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example)
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)
form		0..1	Attachment	Printed reference or actual form
processNote	S	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)
text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages
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)
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)
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example)
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example)
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)
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