PREFIX fhir:
PREFIX fhirvs:
PREFIX xsd:
BASE
start=@ AND {fhir:nodeRole [fhir:treeRoot]}
# Explanation of Benefit resource
CLOSED {
a [fhir:ExplanationOfBenefit];
fhir:nodeRole [fhir:treeRoot]?;
fhir:Resource.id id?; # Logical id of this artifact
fhir:Resource.meta @?; # Metadata about the resource
fhir:Resource.implicitRules @?; # A set of rules under which this
# content was created
fhir:Resource.language @?; # Language of the resource content
fhir:DomainResource.text @?; # Text summary of the resource, for
# human interpretation
fhir:DomainResource.contained @*; # Contained, inline Resources
fhir:DomainResource.extension @*; # Additional content defined by
# implementations
fhir:DomainResource.modifierExtension @*; # Extensions that cannot be ignored
fhir:ExplanationOfBenefit.identifier @*; # Business Identifier for the
# resource
fhir:ExplanationOfBenefit.status @ AND
{fhir:value @fhirvs:explanationofbenefit-status}; # active | cancelled | draft |
# entered-in-error
fhir:ExplanationOfBenefit.type @; # Category or discipline
fhir:ExplanationOfBenefit.subType @?; # More granular claim type
fhir:ExplanationOfBenefit.use @ AND
{fhir:value @fhirvs:claim-use}; # claim | preauthorization |
# predetermination
fhir:ExplanationOfBenefit.patient @; # The recipient of the products and
# services
fhir:ExplanationOfBenefit.billablePeriod @?; # Relevant time frame for the claim
fhir:ExplanationOfBenefit.created @; # Response creation date
fhir:ExplanationOfBenefit.enterer @?; # Author of the claim
fhir:ExplanationOfBenefit.insurer @; # Party responsible for reimbursement
fhir:ExplanationOfBenefit.provider @; # Party responsible for the claim
fhir:ExplanationOfBenefit.priority @?; # Desired processing urgency
fhir:ExplanationOfBenefit.fundsReserveRequested @?; # For whom to reserve funds
fhir:ExplanationOfBenefit.fundsReserve @?; # Funds reserved status
fhir:ExplanationOfBenefit.related @*; # Prior or corollary claims
fhir:ExplanationOfBenefit.prescription @?; # Prescription authorizing services
# or products
fhir:ExplanationOfBenefit.originalPrescription @?; # Original prescription if
# superceded by fulfiller
fhir:ExplanationOfBenefit.payee @?; # Recipient of benefits payable
fhir:ExplanationOfBenefit.referral @?; # Treatment Referral
fhir:ExplanationOfBenefit.facility @?; # Servicing Facility
fhir:ExplanationOfBenefit.claim @?; # Claim reference
fhir:ExplanationOfBenefit.claimResponse @?; # Claim response reference
fhir:ExplanationOfBenefit.outcome @ AND
{fhir:value @fhirvs:remittance-outcome}; # queued | complete | error | partial
fhir:ExplanationOfBenefit.disposition @?; # Disposition Message
fhir:ExplanationOfBenefit.preAuthRef @*; # Preauthorization reference
fhir:ExplanationOfBenefit.preAuthRefPeriod @*; # Preauthorization in-effect period
fhir:ExplanationOfBenefit.careTeam @*; # Care Team members
fhir:ExplanationOfBenefit.supportingInfo @*; # Supporting information
fhir:ExplanationOfBenefit.diagnosis @*; # Pertinent diagnosis information
fhir:ExplanationOfBenefit.procedure @*; # Clinical procedures performed
fhir:ExplanationOfBenefit.precedence @?; # Precedence (primary, secondary,
# etc.)
fhir:ExplanationOfBenefit.insurance @+; # Patient insurance information
fhir:ExplanationOfBenefit.accident @?; # Details of the event
fhir:ExplanationOfBenefit.item @*; # Product or service provided
fhir:ExplanationOfBenefit.addItem @*; # Insurer added line items
fhir:ExplanationOfBenefit.adjudication @*; # Header-level adjudication
fhir:ExplanationOfBenefit.total @*; # Adjudication totals
fhir:ExplanationOfBenefit.payment @?; # Payment Details
fhir:ExplanationOfBenefit.formCode @?; # Printed form identifier
fhir:ExplanationOfBenefit.form @?; # Printed reference or actual form
fhir:ExplanationOfBenefit.processNote @*; # Note concerning adjudication
fhir:ExplanationOfBenefit.benefitPeriod @?; # When the benefits are applicable
fhir:ExplanationOfBenefit.benefitBalance @*; # Balance by Benefit Category
fhir:index xsd:integer? # Relative position in a list
}
# Supporting information
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.supportingInfo.sequence @; # Information instance identifier
fhir:ExplanationOfBenefit.supportingInfo.category @; # Classification of the supplied
# information
fhir:ExplanationOfBenefit.supportingInfo.code @?; # Type of information
( # When it occurred
fhir:ExplanationOfBenefit.supportingInfo.timingDate @ |
fhir:ExplanationOfBenefit.supportingInfo.timingPeriod @
)?;
( # Data to be provided
fhir:ExplanationOfBenefit.supportingInfo.valueBoolean @ |
fhir:ExplanationOfBenefit.supportingInfo.valueString @ |
fhir:ExplanationOfBenefit.supportingInfo.valueQuantity @ |
fhir:ExplanationOfBenefit.supportingInfo.valueAttachment @ |
fhir:ExplanationOfBenefit.supportingInfo.valueReference @
)?;
fhir:ExplanationOfBenefit.supportingInfo.reason @?; # Explanation for the information
fhir:index xsd:integer? # Relative position in a list
}
# Patient insurance information
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.insurance.focal @; # Coverage to be used for
# adjudication
fhir:ExplanationOfBenefit.insurance.coverage @; # Insurance information
fhir:ExplanationOfBenefit.insurance.preAuthRef @*; # Prior authorization reference
# number
fhir:index xsd:integer? # Relative position in a list
}
# Insurer added line items
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.addItem.itemSequence @*; # Item sequence number
fhir:ExplanationOfBenefit.addItem.detailSequence @*; # Detail sequence number
fhir:ExplanationOfBenefit.addItem.subDetailSequence @*; # Subdetail sequence number
fhir:ExplanationOfBenefit.addItem.provider @*; # Authorized providers
fhir:ExplanationOfBenefit.addItem.productOrService @; # Billing, service, product, or drug
# code
fhir:ExplanationOfBenefit.addItem.modifier @*; # Service/Product billing modifiers
fhir:ExplanationOfBenefit.addItem.programCode @*; # Program the product or service is
# provided under
( # Date or dates of service or
# product delivery
fhir:ExplanationOfBenefit.addItem.servicedDate @ |
fhir:ExplanationOfBenefit.addItem.servicedPeriod @
)?;
( # Place of service or where product
# was supplied
fhir:ExplanationOfBenefit.addItem.locationCodeableConcept @ |
fhir:ExplanationOfBenefit.addItem.locationAddress @ |
fhir:ExplanationOfBenefit.addItem.locationReference @
)?;
fhir:ExplanationOfBenefit.addItem.quantity @?; # Count of products or services
fhir:ExplanationOfBenefit.addItem.unitPrice @?; # Fee, charge or cost per item
fhir:ExplanationOfBenefit.addItem.factor @?; # Price scaling factor
fhir:ExplanationOfBenefit.addItem.net @?; # Total item cost
fhir:ExplanationOfBenefit.addItem.bodySite @?; # Anatomical location
fhir:ExplanationOfBenefit.addItem.subSite @*; # Anatomical sub-location
fhir:ExplanationOfBenefit.addItem.noteNumber @*; # Applicable note numbers
fhir:ExplanationOfBenefit.addItem.adjudication @*; # Added items adjudication
fhir:ExplanationOfBenefit.addItem.detail @*; # Insurer added line items
fhir:index xsd:integer? # Relative position in a list
}
# Adjudication totals
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.total.category @; # Type of adjudication information
fhir:ExplanationOfBenefit.total.amount @; # Financial total for the category
fhir:index xsd:integer? # Relative position in a list
}
# Recipient of benefits payable
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.payee.type @?; # Category of recipient
fhir:ExplanationOfBenefit.payee.party @?; # Recipient reference
fhir:index xsd:integer? # Relative position in a list
}
# Prior or corollary claims
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.related.claim @?; # Reference to the related claim
fhir:ExplanationOfBenefit.related.relationship @?; # How the reference claim is related
fhir:ExplanationOfBenefit.related.reference @?; # File or case reference
fhir:index xsd:integer? # Relative position in a list
}
# Care Team members
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.careTeam.sequence @; # Order of care team
fhir:ExplanationOfBenefit.careTeam.provider @; # Practitioner or organization
fhir:ExplanationOfBenefit.careTeam.responsible @?; # Indicator of the lead practitioner
fhir:ExplanationOfBenefit.careTeam.role @?; # Function within the team
fhir:ExplanationOfBenefit.careTeam.qualification @?; # Practitioner credential or
# specialization
fhir:index xsd:integer? # Relative position in a list
}
# Balance by Benefit Category
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.benefitBalance.category @; # Benefit classification
fhir:ExplanationOfBenefit.benefitBalance.excluded @?; # Excluded from the plan
fhir:ExplanationOfBenefit.benefitBalance.name @?; # Short name for the benefit
fhir:ExplanationOfBenefit.benefitBalance.description @?; # Description of the benefit or
# services covered
fhir:ExplanationOfBenefit.benefitBalance.network @?; # In or out of network
fhir:ExplanationOfBenefit.benefitBalance.unit @?; # Individual or family
fhir:ExplanationOfBenefit.benefitBalance.term @?; # Annual or lifetime
fhir:ExplanationOfBenefit.benefitBalance.financial @*; # Benefit Summary
fhir:index xsd:integer? # Relative position in a list
}
# Pertinent diagnosis information
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.diagnosis.sequence @; # Diagnosis instance identifier
( # Nature of illness or problem
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept @ |
fhir:ExplanationOfBenefit.diagnosis.diagnosisReference @
);
fhir:ExplanationOfBenefit.diagnosis.type @*; # Timing or nature of the diagnosis
fhir:ExplanationOfBenefit.diagnosis.onAdmission @?; # Present on admission
fhir:ExplanationOfBenefit.diagnosis.packageCode @?; # Package billing code
fhir:index xsd:integer? # Relative position in a list
}
# Note concerning adjudication
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.processNote.number @?; # Note instance identifier
fhir:ExplanationOfBenefit.processNote.type @ AND
{fhir:value @fhirvs:note-type}?; # display | print | printoper
fhir:ExplanationOfBenefit.processNote.text @?; # Note explanatory text
fhir:ExplanationOfBenefit.processNote.language @?; # Language of the text
fhir:index xsd:integer? # Relative position in a list
}
# Product or service provided
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.item.sequence @; # Item instance identifier
fhir:ExplanationOfBenefit.item.careTeamSequence @*; # Applicable care team members
fhir:ExplanationOfBenefit.item.diagnosisSequence @*; # Applicable diagnoses
fhir:ExplanationOfBenefit.item.procedureSequence @*; # Applicable procedures
fhir:ExplanationOfBenefit.item.informationSequence @*; # Applicable exception and
# supporting information
fhir:ExplanationOfBenefit.item.revenue @?; # Revenue or cost center code
fhir:ExplanationOfBenefit.item.category @?; # Benefit classification
fhir:ExplanationOfBenefit.item.productOrService @; # Billing, service, product, or drug
# code
fhir:ExplanationOfBenefit.item.modifier @*; # Product or service billing
# modifiers
fhir:ExplanationOfBenefit.item.programCode @*; # Program the product or service is
# provided under
( # Date or dates of service or
# product delivery
fhir:ExplanationOfBenefit.item.servicedDate @ |
fhir:ExplanationOfBenefit.item.servicedPeriod @
)?;
( # Place of service or where product
# was supplied
fhir:ExplanationOfBenefit.item.locationCodeableConcept @ |
fhir:ExplanationOfBenefit.item.locationAddress @ |
fhir:ExplanationOfBenefit.item.locationReference @
)?;
fhir:ExplanationOfBenefit.item.quantity @?; # Count of products or services
fhir:ExplanationOfBenefit.item.unitPrice @?; # Fee, charge or cost per item
fhir:ExplanationOfBenefit.item.factor @?; # Price scaling factor
fhir:ExplanationOfBenefit.item.net @?; # Total item cost
fhir:ExplanationOfBenefit.item.udi @*; # Unique device identifier
fhir:ExplanationOfBenefit.item.bodySite @?; # Anatomical location
fhir:ExplanationOfBenefit.item.subSite @*; # Anatomical sub-location
fhir:ExplanationOfBenefit.item.encounter @*; # Encounters related to this billed
# item
fhir:ExplanationOfBenefit.item.noteNumber @*; # Applicable note numbers
fhir:ExplanationOfBenefit.item.adjudication @*; # Adjudication details
fhir:ExplanationOfBenefit.item.detail @*; # Additional items
fhir:index xsd:integer? # Relative position in a list
}
# Clinical procedures performed
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.procedure.sequence @; # Procedure instance identifier
fhir:ExplanationOfBenefit.procedure.type @*; # Category of Procedure
fhir:ExplanationOfBenefit.procedure.date @?; # When the procedure was performed
( # Specific clinical procedure
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept @ |
fhir:ExplanationOfBenefit.procedure.procedureReference @
);
fhir:ExplanationOfBenefit.procedure.udi @*; # Unique device identifier
fhir:index xsd:integer? # Relative position in a list
}
# Header-level adjudication
CLOSED {
fhir:index xsd:integer? # Relative position in a list
}
# Details of the event
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.accident.date @?; # When the incident occurred
fhir:ExplanationOfBenefit.accident.type @?; # The nature of the accident
( # Where the event occurred
fhir:ExplanationOfBenefit.accident.locationAddress @ |
fhir:ExplanationOfBenefit.accident.locationReference @
)?;
fhir:index xsd:integer? # Relative position in a list
}
# Payment Details
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.payment.type @?; # Partial or complete payment
fhir:ExplanationOfBenefit.payment.adjustment @?; # Payment adjustment for non-claim
# issues
fhir:ExplanationOfBenefit.payment.adjustmentReason @?; # Explanation for the variance
fhir:ExplanationOfBenefit.payment.date @?; # Expected date of payment
fhir:ExplanationOfBenefit.payment.amount @?; # Payable amount after adjustment
fhir:ExplanationOfBenefit.payment.identifier @?; # Business identifier for the payment
fhir:index xsd:integer? # Relative position in a list
}
# Additional items
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.item.detail.sequence @; # Product or service provided
fhir:ExplanationOfBenefit.item.detail.revenue @?; # Revenue or cost center code
fhir:ExplanationOfBenefit.item.detail.category @?; # Benefit classification
fhir:ExplanationOfBenefit.item.detail.productOrService @; # Billing, service, product, or drug
# code
fhir:ExplanationOfBenefit.item.detail.modifier @*; # Service/Product billing modifiers
fhir:ExplanationOfBenefit.item.detail.programCode @*; # Program the product or service is
# provided under
fhir:ExplanationOfBenefit.item.detail.quantity @?; # Count of products or services
fhir:ExplanationOfBenefit.item.detail.unitPrice @?; # Fee, charge or cost per item
fhir:ExplanationOfBenefit.item.detail.factor @?; # Price scaling factor
fhir:ExplanationOfBenefit.item.detail.net @?; # Total item cost
fhir:ExplanationOfBenefit.item.detail.udi @*; # Unique device identifier
fhir:ExplanationOfBenefit.item.detail.noteNumber @*; # Applicable note numbers
fhir:ExplanationOfBenefit.item.detail.adjudication @*; # Detail level adjudication details
fhir:ExplanationOfBenefit.item.detail.subDetail @*; # Additional items
fhir:index xsd:integer? # Relative position in a list
}
# Insurer added line items
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.addItem.detail.productOrService @; # Billing, service, product, or drug
# code
fhir:ExplanationOfBenefit.addItem.detail.modifier @*; # Service/Product billing modifiers
fhir:ExplanationOfBenefit.addItem.detail.quantity @?; # Count of products or services
fhir:ExplanationOfBenefit.addItem.detail.unitPrice @?; # Fee, charge or cost per item
fhir:ExplanationOfBenefit.addItem.detail.factor @?; # Price scaling factor
fhir:ExplanationOfBenefit.addItem.detail.net @?; # Total item cost
fhir:ExplanationOfBenefit.addItem.detail.noteNumber @*; # Applicable note numbers
fhir:ExplanationOfBenefit.addItem.detail.adjudication @*; # Added items adjudication
fhir:ExplanationOfBenefit.addItem.detail.subDetail @*; # Insurer added line items
fhir:index xsd:integer? # Relative position in a list
}
# Adjudication details
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.item.adjudication.category @; # Type of adjudication information
fhir:ExplanationOfBenefit.item.adjudication.reason @?; # Explanation of adjudication outcome
fhir:ExplanationOfBenefit.item.adjudication.amount @?; # Monetary amount
fhir:ExplanationOfBenefit.item.adjudication.value @?; # Non-monitary value
fhir:index xsd:integer? # Relative position in a list
}
# Added items adjudication
CLOSED {
fhir:index xsd:integer? # Relative position in a list
}
# Benefit Summary
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.benefitBalance.financial.type @; # Benefit classification
( # Benefits allowed
fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt @ |
fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString @ |
fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney @
)?;
( # Benefits used
fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt @ |
fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney @
)?;
fhir:index xsd:integer? # Relative position in a list
}
# Detail level adjudication details
CLOSED {
fhir:index xsd:integer? # Relative position in a list
}
# Insurer added line items
CLOSED {
fhir:Element.id string?; # Unique id for inter-element
# referencing
fhir:Element.extension @*; # Additional content defined by
# implementations
fhir:BackboneElement.modifierExtension @*; # Extensions that cannot be ignored
# even if unrecognized
fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrService @; # Billing, service, product, or drug
# code
fhir:ExplanationOfBenefit.addItem.detail.subDetail.modifier @*; # Service/Product billing modifiers
fhir:ExplanationOfBenefit.addItem.detail.subDetail.quantity @