| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ExplanationOfBenefit
|
C | C4BBExplanationOfBenefit |
EOB-oral-meta-profile-version:
Oral EOB: meta.profile with canonical and major.minor. version required. Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
|
type
|
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: oral |
|
provider
|
Reference (C4BB Practitioner) | |||
|
careTeam
|
C | EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner | ||
|
role
|
1.. | Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set ( required ) | ||
|
qualification
|
S | Binding: Healthcare Provider Taxonomy ( required ) | ||
Slices for supportingInfo
|
Slice: Unordered, Open by pattern:category | |||
supportingInfo:clmrecvddate
|
S | 0..1 | Claim received date | |
category
|
S | 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.. | date | |
|
supportingInfo:servicefacility
|
S | 0..1 | Service facility | |
|
category
|
S | 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 |
|
|
Slices for value[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
value[x]:valueReference
|
S | 1..1 | Reference (C4BB Organization) | |
|
supportingInfo:orthodontics
|
S | 0..1 | Orthodontics treatment indicator | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: orthodontics |
|
|
code
|
||||
|
Slices for timing[x]
|
Slice: Unordered, Open by type:$this | |||
|
timing[x]:timingDate
|
0..1 | date | Orthodontics appliance application date (200) | |
value[x]
|
S | 1.. | Quantity | Total number of months for orthodontia |
|
supportingInfo:prosthesis
|
S | 0..1 | Prosthesis | |
|
category
|
S | 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: prosthesis |
|
|
Slices for timing[x]
|
Slice: Unordered, Open by type:$this | |||
|
timing[x]:timingDate
|
0..1 | date | Date of prior prosthesis replacement (203) | |
|
value[x]
|
S | 1.. | boolean | Prosthesis replacement indicator (202 |
|
supportingInfo:additionalbodysite
|
S | 0..* |
Additional tooth number or oral cavity code |
|
|
sequence
|
S | |||
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: additionalbodysite |
|
|
code
|
S | 1.. | Binding: Oral Body Site Value Set ( required ) | |
|
supportingInfo:missingtoothnumber
|
S | 0..* |
Missing tooth number |
|
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: missingtoothnumber |
|
|
code
|
S | 1.. | Binding: American Dental Association Universal Numbering Value Set ( required ) | |
|
supportingInfo:medicalrecordnumber
|
S | 0..1 | Medical record number | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: medicalrecordnumber |
|
|
Slices for value[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
|
value[x]:valueString
|
S | 1..1 | string | |
|
supportingInfo:patientaccountnumber
|
S | 0..1 | Patient account number | |
|
category
|
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: patientaccountnumber |
|
|
Slices for value[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
|
value[x]:valueString
|
S | 1..1 | string | |
|
diagnosis
|
S | |||
|
sequence
|
||||
|
diagnosis[x]
|
S | CodeableConcept | Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set ( required ) | |
|
type
|
S | 1..1 | Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set ( required ) | |
|
item
|
||||
|
informationSequence
|
S | |||
|
productOrService
|
S | Binding: ADA Code on Dental Procedures and Nomenclature Value Set ( required ) | ||
|
modifier
|
S | Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set ( required ) | ||
|
serviced[x]
|
S | 1.. | ||
|
location[x]
|
S | 1.. | CodeableConcept | Binding: CMS Place of Service Codes (POS) Value Set ( required ) |
|
quantity
|
||||
|
bodySite
|
S |
First tooth number or oral cavity code Binding: Oral Body Site Value Set ( required ) |
||
|
subSite
|
Tooth surface for all teeth on line Binding: US Surface Codes Set Value Set ( required ) |
|||
|
Slices for adjudication
|
S | 2 .. | Slice: Unordered, Open by pattern:category | |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
Binding: C4BB Adjudication Category Discriminator Value Set ( extensible ) | |||
|
adjudication:adjudicationamounttype
|
S | 1..* |
Amounts |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | 1.. | ||
|
adjudication:adjustmentreason
|
S | 0..1 | Reason codes used to interpret the Non-Covered Amount (92) | |
|
category
|
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: adjustmentreason |
|
|
reason
|
S | 1.. | Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set ( required ) | |
|
adjudication:benefitpaymentstatus
|
S | 1..1 | Indicates the in network or out of network payment status of the claim. (142) | |
|
category
|
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: benefitpaymentstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Benefit Payment Status Value Set ( required ) | |
|
adjudication:allowedunits
|
S | 0..1 | 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
|
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 |
|
|
Slices for adjudication
|
S | 2 .. | BackboneElement | Slice: Unordered, Open by pattern:category |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | Binding: C4BB Adjudication Category Discriminator Value Set ( extensible ) | ||
|
adjudication:billingnetworkstatus
|
S | 0..1 | Billing provider network status | |
|
category
|
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: billingnetworkstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Provider Network Status Value Set ( required ) | |
|
adjudication:renderingnetworkstatus
|
S | 1..1 | Rendering provider network status | |
|
category
|
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: renderingnetworkstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Provider Network Status Value Set ( required ) | |
|
adjudication:benefitpaymentstatus
|
S | 1..* |
Indicates the in network or out of network payment status of the claim. (142) |
|
|
category
|
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: benefitpaymentstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Benefit Payment Status Value Set ( required ) | |
|
Slices for total
|
Slice: Unordered, Open by pattern:category | |||
|
total:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | |||
|
amount
|
||||
|
total:adjudicationamounttype
|
S | 1..* |
Total adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
Documentation for this format
|
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