| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ExplanationOfBenefit
|
C | C4BBExplanationOfBenefit |
EOB-institutional-outpatient-meta-profile-version:
Institutional Outpatient EOB: meta.profile with canonical and major.minor. version required. EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both |
|
identifier
|
S | |||
|
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: institutional |
|
|
subType
|
S | 1.. |
Binding:
C4BB Institutional Claim SubType Value Set
( required
) 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/C4BBInstitutionalClaimSubType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: outpatient |
|
|
created
|
S | |||
provider
|
Reference (C4BB Organization) | |||
|
careTeam
|
C |
EOB-inst-careTeam-practitioner:
Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set |
||
|
role
|
1.. | Binding: C4BB Claim Institutional Care Team Role Value Set ( required ) | ||
|
qualification
|
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:typeofbill
|
S | 0..1 | Type of bill | |
|
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: typeofbill |
|
|
code
|
S | 1.. | Binding: NUBC Type of Bill Codes Value Set ( required ) | |
|
supportingInfo:pointoforigin
|
S | 0..1 | Point of origin for admission or visit | |
|
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: pointoforigin |
|
|
code
|
S | 1.. | Binding: NUBC Point Of Origin Value Set ( required ) | |
|
supportingInfo:admtype
|
S | 0..1 | Admission type | |
|
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: admtype |
|
|
code
|
S | 1.. | Binding: NUBC Priority (Type) of Admission or Visit Value Set ( required ) | |
|
supportingInfo:discharge-status
|
S | 0..1 | Discharge status | |
|
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: discharge-status |
|
|
code
|
S | 1.. | Binding: NUBC Patient Discharge Status Codes 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
|
1.. | |||
|
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 Outpatient Institutional Diagnosis Type Value Set ( required ) | |
|
item
|
C | adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | ||
|
revenue
|
S | Binding: NUBC Revenue Codes Value Set ( required ) | ||
|
productOrService
|
S | Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set ( required ) | ||
|
modifier
|
S | Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set ( required ) | ||
|
serviced[x]
|
S | 1.. | date | |
|
quantity
|
S | |||
|
Slices for adjudication
|
S | 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 | 0..* |
Line level adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | 1.. | ||
|
adjudication:adjustmentreason
|
S | 0..* |
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: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 |
|
|
value
|
S | 1.. | ||
|
Slices for adjudication
|
S | 1 .. | 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 networking 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: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:adjudicationamounttype
|
S | 0..* |
Claim level adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | 1.. | ||
|
adjudication:adjustmentreason
|
S | 0..* |
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 ) | |
|
Slices for total
|
Slice: Unordered, Open by pattern:category | |||
|
total:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | Binding: C4BB Total Category Discriminator Value Set ( extensible ) | ||
|
amount
|
||||
|
total:adjudicationamounttype
|
S | 1..* |
Total adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | |||
|
payment
|
||||
|
date
|
S | |||
|
processNote
|
||||
|
text
|
S | |||
|
Documentation for this format
|
||||