Blue Button 2.0 Implementation Guide

SD.5 StructureDefinition-bluebutton-outpatient-claim

This profile sets minimum expectations for the [ExplanationOfBenefit] Outpatient Claim resource to record, search and fetch basic demographics and other administrative information about an individual Outpatient Claim. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Blue Button Outpatient Claim profile:

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Outpatient Claim must have:

  1. EOB identifiers
  2. a status
  3. a type
  4. a patient
  5. a billable period
  6. an insurance
  7. an item
  8. a payment
  9. the following EOB level extensions: - outpatient-nch-profnl-cmpnt-chrg-amt-extension - outpatient-nch-bene-ptb-ddctbl-amt-extension - outpatient-nch-bene-ptb-coinsrnc-amt-extension - outpatient-clm-op-prvdr-pmt-amt-extension - outpatient-clm-op-bene-pmt-amt-extension - outpatient-nch-bene-blood-ddctbl-lblty-am-extension - outpatient-clm-mdcr-non-pmt-rsn-cd-extension - outpatient-prpayamt-extension - outpatient-fi-num-extension

If the data is available a Outpatient Claim shall include:

  1. a provider
  2. an organization
  3. a facility
  4. information
  5. a care team
  6. diagnoses
  7. a procedure
  8. a total cost

Profile specific implementation guidance:

  • none

Examples

  • none

SD.5.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim.html

Published on Wed Mar 21 16:11:24 UTC 2018 as a draft by CMS Blue Button 2.0 Team.

This profile builds on ExplanationOfBenefit

Complete Summary of the Mandatory Requirements

  1. One or more … in ExplanationOfBenefit.identifier
    • each ExplanationOfBenefit.identifier must have:
      • an identifier.system
      • an identifier.value that is unique within the system.

  2. One status in ExplanationOfBenefit.status

  3. One type in ExplanationOfBenefit.type
    • an ExplanationOfBenefit.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  4. One patient in ExplanationOfBenefit.patient
    • an ExplanationOfBenefit.patient must have:
      • a patient.reference
  5. One type in ExplanationOfBenefit.billablePeriod
    • an ExplanationOfBenefit.billablePeriod must have:
      • a billablePeriod.start
      • a billablePeriod.end
      • a billablePeriod.outpatient-claim-query-cd-extension
  6. One insurance in ExplanationOfBenefit.insurance
    • an ExplanationOfBenefit.insurance must have:
      • an insurance.coverage, and a coverage must have: - a coverage.reference
  7. One or more item in ExplanationOfBenefit.item
    • an ExplanationOfBenefit.item must have:
      • an item.sequence
      • a item.careTeamLinkId
      • a item.revenue, and each revenue must have:
        • a revenue.coding, and each coding must have: - a coding.system - a coding.code
        • a revenue.outpatient-rev-cntr-stus-ind-cd-extension
      • an item.service, and each service must have:
        • a service.coding, and each coding must have: - a coding.system - a coding.code
        • a service.outpatient-rev-cntr-ide-ndc-upc-num-extension
      • an item.modifier, and each modifier must have:
        • a modifier.coding, and each coding must have: - a coding.system - a coding.code
      • an item.serviceDate
      • an item.locationAddress, and each locationAddress must have:
        • a locationAddress.state
      • an item.quantity, and each quantity must have: - a quantity.value
      • one or more item.adjudication, and each adjudication must have: - an adjudication.category, and each category must have: - a category.coding, and each coding must have: - a coding.system - a coding.code
        • an adjudication.reason, and each reason must have: - a reason.coding, and each coding must have: - a coding.system - a coding.code
        • an adjudication.amount, and each amount must have: - a amount.value - a amount.system - a amount.code
      • an item.outpatient-rev-cntr-ndc-qty-extension
  8. A payment in ExplanationOfBenefit.payment
    • an ExplanationOfBenefit.payment must have:
      • a payment.amount, and each amount must have:
        • a amount.value
        • a amount.system
  9. The following ExplanationOfBenefit extensions: - ExplanationOfBenefit.outpatient-nch-profnl-cmpnt-chrg-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-ptb-ddctbl-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-ptb-coinsrnc-amt-extension - ExplanationOfBenefit.outpatient-clm-op-prvdr-pmt-amt-extension - ExplanationOfBenefit.outpatient-clm-op-bene-pmt-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-blood-ddctbl-lblty-am-extension - ExplanationOfBenefit.outpatient-clm-mdcr-non-pmt-rsn-cd-extension - ExplanationOfBenefit.outpatient-prpayamt-extension - ExplanationOfBenefit.outpatient-fi-num-extension

Summary of the Must Support Requirements

Additionally your system must support:

  1. One provider in ExplanationOfBenefit.provider
    • an ExplanationOfBenefit.provider must have:
      • a provider.identifier
  2. One organization in ExplanationOfBenefit.organization
    • an ExplanationOfBenefit.organization must have:
      • a organization.identifier
  3. One facility in ExplanationOfBenefit.facility
    • an ExplanationOfBenefit.facility must have:
      • a facility.identifier
      • a facility.outpatient-clm-fac-type-cd-extension
  4. One or more information in ExplanationOfBenefit.information
    • an ExplanationOfBenefit.information must have:
      • an information.sequence
      • an information.category, and each category must have: - a category.coding, and each coding must have: - a coding.system - a coding.code
      • an information.code, and each cod must have:
        • a ccod.coding, and each coding must have: - a coding.system - a coding.code
      • an information.value
  5. One or more care team in ExplanationOfBenefit.careTeam
    • an ExplanationOfBenefit.careTeam must have:
      • a careTeam.sequence
      • a careTeam.provider, and each provider must have: - a provider.identifer
      • a careTeam.role, and each role must have: - a role.coding, and each coding must have: - a coding.system - a coding.code
  6. One or more diagnosis in ExplanationOfBenefit.diagnosis
    • an ExplanationOfBenefit.diagnosis must have:
      • a diagnosis.sequence
      • a diagnosis.diagnosis
      • a diagnosis.type, and each type must have: - a type.coding, and each coding must have: - a coding.system - a coding.code
      • a diagnoisis.packageCode, and each packageCode must have: - a packageCode.coding, and each coding must have: - a coding.system - a coding.code`
      • a diagnosis.outpatient-clm-poa-ind-sw1-extension
  7. One or more procedure in ExplanationOfBenefit.procedure
    • an ExplanationOfBenefit.procedure must have:
      • a procedure.sequence
      • a procedure.date
      • a diagnosis.procedure
  8. One total cost in ExplanationOfBenefit.totalCost
    • an ExplanationOfBenefit.totalCost must have:
      • an totalCost.value
      • an information.system
      • an information.code
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id 1..
... meta ..0
... implicitRules ..0
... language ..0
... text ..0
... contained ..0
... identifier 1..
.... id ..0
.... use ..0
.... type ..0
.... system 1..
.... value 1..
.... period ..0
.... assigner ..0
... status 1..
... type 1..
.... id ..0
.... coding 1..
..... id ..0
..... system 1..
..... version ..0
..... code 1..
..... display 1..
..... userSelected ..0
... subType ..0
... patient 1..
.... id ..0
.... reference 1..
.... identifier ..0
.... display ..0
... billablePeriod 1..
.... id ..0
.... start 1..
.... end 1..
.... bluebutton-outpatient-claim-query-cd-extension 1..1CodingClaim Query Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension
... created ..0
... enterer ..0
... insurer ..0
... referral ..0
... claim ..0
... claimResponse ..0
... outcome ..0
... disposition ..0
... related ..0
... prescription ..0
... originalPrescription ..0
... payee ..0
... precedence ..0
... insurance 1..
.... id ..0
.... coverage 1..
..... id ..0
..... reference 1..
..... identifier ..0
..... display ..0
.... preAuthRef ..0
... accident ..0
... employmentImpacted ..0
... hospitalization ..0
... item 1..
.... id ..0
.... careTeamLinkId ..1
.... diagnosisLinkId ..0
.... procedureLinkId ..0
.... informationLinkId ..0
.... category ..0
.... programCode ..0
.... servicedDate date
..... id ..0
.... locationAddress Address
..... id ..0
..... use ..0
..... type ..0
..... text ..0
..... line ..0
..... city ..0
..... district ..0
..... state 1..
..... postalCode ..0
..... country ..0
..... period ..0
.... unitPrice ..0
.... factor ..0
.... net ..0
.... udi ..0
.... bodySite ..0
.... subSite ..0
.... encounter ..0
.... noteNumber ..0
.... detail ..0
.... bluebutton-outpatient-rev-cntr-ndc-qty-extension 1..1QuantityRevenue Center National Drug Code (NDC) Quantity
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension
... addItem ..0
... unallocdeductible ..0
... totalBenefit ..0
... payment 1..
.... id ..0
.... type ..0
.... adjustment ..0
.... adjustmentReason ..0
.... date ..0
.... amount 1..
..... id ..0
..... value 1..
..... comparator ..0
..... unit ..0
..... system 1..
..... code ..0
.... identifier ..0
... form ..0
... processNote ..0
... benefitBalance ..0
... bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension 1..1MoneyProfessional Component Charge Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension
... bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension 1..1MoneyNCH Beneficiary Part B Deductible Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension
... bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension 1..1MoneyNCH Beneficiary Part B Coinsurance Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension
... bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension 1..1MoneyClaim Outpatient Pr ovider Payment Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension
... bluebutton-outpatient-clm-op-bene-pmt-amt-extension 1..1MoneyClaim Outpatient Payment Amount to Beneficiary
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension
... bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension 1..1MoneyNCH Beneficiary Blood Deductible Liability Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension
... bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension 1..1CodingClaim Medicare Non Payment Reason Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension
... bluebutton-outpatient-prpayamt-extension 1..1MoneyNCH Primary Payer (if not Medicare) Claim Paid Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension
... bluebutton-outpatient-fi-num-extension 1..1IdentifierFI or MAC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id Σ1..1idLogical id of this artifact
... bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension 1..1MoneyProfessional Component Charge Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension
... bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension 1..1MoneyNCH Beneficiary Part B Deductible Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension
... bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension 1..1MoneyNCH Beneficiary Part B Coinsurance Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension
... bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension 1..1MoneyClaim Outpatient Provider Payment Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension
... bluebutton-outpatient-clm-op-bene-pmt-amt-extension 1..1MoneyClaim Outpatient Payment Amount to Beneficiary
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension
... bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension 1..1MoneyNCH Beneficiary Blood Deductible Liability Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension
... bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension 1..1CodingClaim Medicare Non Payment Reason Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension
Binding: Claim Medicare Non Payment Reason Code (required)
... bluebutton-outpatient-prpayamt-extension 1..1MoneyNCH Primary Payer (if not Medicare) Claim Paid Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension
... bluebutton-outpatient-fi-num-extension 1..1IdentifierFI or MAC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension
... identifier 1..*IdentifierBusiness Identifier
.... system Σ1..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
.... value Σ1..1stringThe value that is unique
Example General': 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type 1..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
.... coding Σ1..*CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
.... text Σ0..1stringPlain text representation of the concept
... patient 1..1Reference(Patient)The subject of the Products and Services
.... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... billablePeriod 1..1PeriodPeriod for charge submission
.... bluebutton-outpatient-claim-query-cd-extension 1..1CodingClaim Query Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension
Binding: Claim Query Code (required)
.... start ΣI1..1dateTimeStarting time with inclusive boundary
.... end ΣI1..1dateTimeEnd time with inclusive boundary, if not ongoing
... provider 0..1Reference(Practitioner)Responsible provider for the claim
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... organization 0..1Reference(Organization)Responsible organization for the claim
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... facility 0..1Reference(Location)Servicing Facility
.... bluebutton-outpatient-clm-fac-type-cd-extension 1..1CodingClaim Facility Type Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-fac-type-cd-extension
Binding: Claim Facility Type Code (required)
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
Binding: Information Categories (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
.... code 1..1CodeableConceptType of information
Binding: Exception Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
.... value[x] 0..1string, Quantity, Attachment, Reference(Resource)Additional Data or supporting information
... careTeam 0..*BackboneElementCare Team members
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner), Reference(Organization)Member of the Care Team
..... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
... diagnosis 0..*BackboneElementList of Diagnosis
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1CodeableConcept, Reference(Condition)Patient's diagnosis
Binding: ICD-10 Codes (example)
.... type 0..1CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example)
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ0..1uriIdentity of the terminology system
...... code Σ0..1codeSymbol in syntax defined by the system
.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
... procedure 0..*BackboneElementProcedures performed
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1CodeableConcept, Reference(Procedure)Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example)
... insurance 1..1BackboneElementInsurance or medical plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 1..1Reference(Coverage)Insurance information
..... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... item 1..*BackboneElementGoods and Services
.... bluebutton-outpatient-rev-cntr-ndc-qty-extension 1..1QuantityRevenue Center National Drug Code (NDC) Quantity
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension
Binding: Revenue Center NDC Quantity Qualifier Code (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntService instance
.... careTeamLinkId 0..1positiveIntApplicable careteam members
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... bluebutton-outpatient-rev-cntr-stus-ind-cd-extension 1..1CodingRevenue Center Status Indicator Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-stus-ind-cd-extension
Binding: Revenue Center Status Indicator Code (required)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension 1..1CodingRevenue Center IDE, NDC, or UPC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... version Σ1..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... servicedDate 0..1dateDate or dates of Service
..... value 0..1Primitive value for date
.... locationAddress 0..1AddressPlace of service
Binding: Example Service Place Codes (example)
..... state Σ1..1stringSub-unit of country (abbreviations ok)
.... quantity 0..1SimpleQuantityCount of Products or Services
..... value Σ0..1decimalNumerical value (with implicit precision)
.... adjudication 0..*BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
...... coding Σ0..*CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ1..1stringRepresentation defined by the system
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example)
...... coding Σ0..*CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
....... code Σ1..1codeSymbol in syntax defined by the system
..... amount 0..1MoneyMonetary amount
...... value Σ1..1decimalNumerical value (with implicit precision)
...... system ΣI1..1uriSystem that defines coded unit form
...... code Σ1..1codeCoded form of the unit
... totalCost 0..1MoneyTotal Cost of service from the Claim
.... value Σ1..1decimalNumerical value (with implicit precision)
.... system ΣI1..1uriSystem that defines coded unit form
.... code Σ1..1codeCoded form of the unit
... payment 1..1BackboneElementPayment (if paid)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... amount 1..1MoneyPayable amount after adjustment
..... value Σ1..1decimalNumerical value (with implicit precision)
..... system ΣI1..1uriSystem that defines coded unit form

doco Documentation for this format

Complete Summary of the Mandatory Requirements

  1. One or more … in ExplanationOfBenefit.identifier
    • each ExplanationOfBenefit.identifier must have:
      • an identifier.system
      • an identifier.value that is unique within the system.

  2. One status in ExplanationOfBenefit.status

  3. One type in ExplanationOfBenefit.type
    • an ExplanationOfBenefit.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  4. One patient in ExplanationOfBenefit.patient
    • an ExplanationOfBenefit.patient must have:
      • a patient.reference
  5. One type in ExplanationOfBenefit.billablePeriod
    • an ExplanationOfBenefit.billablePeriod must have:
      • a billablePeriod.start
      • a billablePeriod.end
      • a billablePeriod.outpatient-claim-query-cd-extension
  6. One insurance in ExplanationOfBenefit.insurance
    • an ExplanationOfBenefit.insurance must have:
      • an insurance.coverage, and a coverage must have: - a coverage.reference
  7. One or more item in ExplanationOfBenefit.item
    • an ExplanationOfBenefit.item must have:
      • an item.sequence
      • a item.careTeamLinkId
      • a item.revenue, and each revenue must have:
        • a revenue.coding, and each coding must have: - a coding.system - a coding.code
        • a revenue.outpatient-rev-cntr-stus-ind-cd-extension
      • an item.service, and each service must have:
        • a service.coding, and each coding must have: - a coding.system - a coding.code
        • a service.outpatient-rev-cntr-ide-ndc-upc-num-extension
      • an item.modifier, and each modifier must have:
        • a modifier.coding, and each coding must have: - a coding.system - a coding.code
      • an item.serviceDate
      • an item.locationAddress, and each locationAddress must have:
        • a locationAddress.state
      • an item.quantity, and each quantity must have: - a quantity.value
      • one or more item.adjudication, and each adjudication must have: - an adjudication.category, and each category must have: - a category.coding, and each coding must have: - a coding.system - a coding.code
        • an adjudication.reason, and each reason must have: - a reason.coding, and each coding must have: - a coding.system - a coding.code
        • an adjudication.amount, and each amount must have: - a amount.value - a amount.system - a amount.code
      • an item.outpatient-rev-cntr-ndc-qty-extension
  8. A payment in ExplanationOfBenefit.payment
    • an ExplanationOfBenefit.payment must have:
      • a payment.amount, and each amount must have:
        • a amount.value
        • a amount.system
  9. The following ExplanationOfBenefit extensions: - ExplanationOfBenefit.outpatient-nch-profnl-cmpnt-chrg-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-ptb-ddctbl-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-ptb-coinsrnc-amt-extension - ExplanationOfBenefit.outpatient-clm-op-prvdr-pmt-amt-extension - ExplanationOfBenefit.outpatient-clm-op-bene-pmt-amt-extension - ExplanationOfBenefit.outpatient-nch-bene-blood-ddctbl-lblty-am-extension - ExplanationOfBenefit.outpatient-clm-mdcr-non-pmt-rsn-cd-extension - ExplanationOfBenefit.outpatient-prpayamt-extension - ExplanationOfBenefit.outpatient-fi-num-extension

Summary of the Must Support Requirements

Additionally your system must support:

  1. One provider in ExplanationOfBenefit.provider
    • an ExplanationOfBenefit.provider must have:
      • a provider.identifier
  2. One organization in ExplanationOfBenefit.organization
    • an ExplanationOfBenefit.organization must have:
      • a organization.identifier
  3. One facility in ExplanationOfBenefit.facility
    • an ExplanationOfBenefit.facility must have:
      • a facility.identifier
      • a facility.outpatient-clm-fac-type-cd-extension
  4. One or more information in ExplanationOfBenefit.information
    • an ExplanationOfBenefit.information must have:
      • an information.sequence
      • an information.category, and each category must have: - a category.coding, and each coding must have: - a coding.system - a coding.code
      • an information.code, and each cod must have:
        • a ccod.coding, and each coding must have: - a coding.system - a coding.code
      • an information.value
  5. One or more care team in ExplanationOfBenefit.careTeam
    • an ExplanationOfBenefit.careTeam must have:
      • a careTeam.sequence
      • a careTeam.provider, and each provider must have: - a provider.identifer
      • a careTeam.role, and each role must have: - a role.coding, and each coding must have: - a coding.system - a coding.code
  6. One or more diagnosis in ExplanationOfBenefit.diagnosis
    • an ExplanationOfBenefit.diagnosis must have:
      • a diagnosis.sequence
      • a diagnosis.diagnosis
      • a diagnosis.type, and each type must have: - a type.coding, and each coding must have: - a coding.system - a coding.code
      • a diagnoisis.packageCode, and each packageCode must have: - a packageCode.coding, and each coding must have: - a coding.system - a coding.code`
      • a diagnosis.outpatient-clm-poa-ind-sw1-extension
  7. One or more procedure in ExplanationOfBenefit.procedure
    • an ExplanationOfBenefit.procedure must have:
      • a procedure.sequence
      • a procedure.date
      • a diagnosis.procedure
  8. One total cost in ExplanationOfBenefit.totalCost
    • an ExplanationOfBenefit.totalCost must have:
      • an totalCost.value
      • an information.system
      • an information.code

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id 1..
... meta ..0
... implicitRules ..0
... language ..0
... text ..0
... contained ..0
... identifier 1..
.... id ..0
.... use ..0
.... type ..0
.... system 1..
.... value 1..
.... period ..0
.... assigner ..0
... status 1..
... type 1..
.... id ..0
.... coding 1..
..... id ..0
..... system 1..
..... version ..0
..... code 1..
..... display 1..
..... userSelected ..0
... subType ..0
... patient 1..
.... id ..0
.... reference 1..
.... identifier ..0
.... display ..0
... billablePeriod 1..
.... id ..0
.... start 1..
.... end 1..
.... bluebutton-outpatient-claim-query-cd-extension 1..1CodingClaim Query Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension
... created ..0
... enterer ..0
... insurer ..0
... referral ..0
... claim ..0
... claimResponse ..0
... outcome ..0
... disposition ..0
... related ..0
... prescription ..0
... originalPrescription ..0
... payee ..0
... precedence ..0
... insurance 1..
.... id ..0
.... coverage 1..
..... id ..0
..... reference 1..
..... identifier ..0
..... display ..0
.... preAuthRef ..0
... accident ..0
... employmentImpacted ..0
... hospitalization ..0
... item 1..
.... id ..0
.... careTeamLinkId ..1
.... diagnosisLinkId ..0
.... procedureLinkId ..0
.... informationLinkId ..0
.... category ..0
.... programCode ..0
.... servicedDate date
..... id ..0
.... locationAddress Address
..... id ..0
..... use ..0
..... type ..0
..... text ..0
..... line ..0
..... city ..0
..... district ..0
..... state 1..
..... postalCode ..0
..... country ..0
..... period ..0
.... unitPrice ..0
.... factor ..0
.... net ..0
.... udi ..0
.... bodySite ..0
.... subSite ..0
.... encounter ..0
.... noteNumber ..0
.... detail ..0
.... bluebutton-outpatient-rev-cntr-ndc-qty-extension 1..1QuantityRevenue Center National Drug Code (NDC) Quantity
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension
... addItem ..0
... unallocdeductible ..0
... totalBenefit ..0
... payment 1..
.... id ..0
.... type ..0
.... adjustment ..0
.... adjustmentReason ..0
.... date ..0
.... amount 1..
..... id ..0
..... value 1..
..... comparator ..0
..... unit ..0
..... system 1..
..... code ..0
.... identifier ..0
... form ..0
... processNote ..0
... benefitBalance ..0
... bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension 1..1MoneyProfessional Component Charge Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension
... bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension 1..1MoneyNCH Beneficiary Part B Deductible Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension
... bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension 1..1MoneyNCH Beneficiary Part B Coinsurance Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension
... bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension 1..1MoneyClaim Outpatient Pr ovider Payment Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension
... bluebutton-outpatient-clm-op-bene-pmt-amt-extension 1..1MoneyClaim Outpatient Payment Amount to Beneficiary
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension
... bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension 1..1MoneyNCH Beneficiary Blood Deductible Liability Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension
... bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension 1..1CodingClaim Medicare Non Payment Reason Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension
... bluebutton-outpatient-prpayamt-extension 1..1MoneyNCH Primary Payer (if not Medicare) Claim Paid Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension
... bluebutton-outpatient-fi-num-extension 1..1IdentifierFI or MAC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id Σ1..1idLogical id of this artifact
... bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension 1..1MoneyProfessional Component Charge Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension
... bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension 1..1MoneyNCH Beneficiary Part B Deductible Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension
... bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension 1..1MoneyNCH Beneficiary Part B Coinsurance Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension
... bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension 1..1MoneyClaim Outpatient Provider Payment Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension
... bluebutton-outpatient-clm-op-bene-pmt-amt-extension 1..1MoneyClaim Outpatient Payment Amount to Beneficiary
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension
... bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension 1..1MoneyNCH Beneficiary Blood Deductible Liability Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension
... bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension 1..1CodingClaim Medicare Non Payment Reason Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension
Binding: Claim Medicare Non Payment Reason Code (required)
... bluebutton-outpatient-prpayamt-extension 1..1MoneyNCH Primary Payer (if not Medicare) Claim Paid Amount
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension
... bluebutton-outpatient-fi-num-extension 1..1IdentifierFI or MAC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension
... identifier 1..*IdentifierBusiness Identifier
.... system Σ1..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
.... value Σ1..1stringThe value that is unique
Example General': 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type 1..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
.... coding Σ1..*CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
.... text Σ0..1stringPlain text representation of the concept
... patient 1..1Reference(Patient)The subject of the Products and Services
.... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... billablePeriod 1..1PeriodPeriod for charge submission
.... bluebutton-outpatient-claim-query-cd-extension 1..1CodingClaim Query Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension
Binding: Claim Query Code (required)
.... start ΣI1..1dateTimeStarting time with inclusive boundary
.... end ΣI1..1dateTimeEnd time with inclusive boundary, if not ongoing
... provider 0..1Reference(Practitioner)Responsible provider for the claim
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... organization 0..1Reference(Organization)Responsible organization for the claim
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... facility 0..1Reference(Location)Servicing Facility
.... bluebutton-outpatient-clm-fac-type-cd-extension 1..1CodingClaim Facility Type Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-fac-type-cd-extension
Binding: Claim Facility Type Code (required)
.... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
Binding: Information Categories (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
.... code 1..1CodeableConceptType of information
Binding: Exception Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
.... value[x] 0..1string, Quantity, Attachment, Reference(Resource)Additional Data or supporting information
... careTeam 0..*BackboneElementCare Team members
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner), Reference(Organization)Member of the Care Team
..... identifier Σ1..1IdentifierLogical reference, when literal reference is not known
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
... diagnosis 0..*BackboneElementList of Diagnosis
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1CodeableConcept, Reference(Condition)Patient's diagnosis
Binding: ICD-10 Codes (example)
.... type 0..1CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example)
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ0..1uriIdentity of the terminology system
...... code Σ0..1codeSymbol in syntax defined by the system
.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
... procedure 0..*BackboneElementProcedures performed
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1CodeableConcept, Reference(Procedure)Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example)
... insurance 1..1BackboneElementInsurance or medical plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 1..1Reference(Coverage)Insurance information
..... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... item 1..*BackboneElementGoods and Services
.... bluebutton-outpatient-rev-cntr-ndc-qty-extension 1..1QuantityRevenue Center National Drug Code (NDC) Quantity
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension
Binding: Revenue Center NDC Quantity Qualifier Code (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntService instance
.... careTeamLinkId 0..1positiveIntApplicable careteam members
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example)
..... bluebutton-outpatient-rev-cntr-stus-ind-cd-extension 1..1CodingRevenue Center Status Indicator Code
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-stus-ind-cd-extension
Binding: Revenue Center Status Indicator Code (required)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension 1..1CodingRevenue Center IDE, NDC, or UPC Number
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... version Σ1..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example)
..... coding Σ0..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... servicedDate 0..1dateDate or dates of Service
..... value 0..1Primitive value for date
.... locationAddress 0..1AddressPlace of service
Binding: Example Service Place Codes (example)
..... state Σ1..1stringSub-unit of country (abbreviations ok)
.... quantity 0..1SimpleQuantityCount of Products or Services
..... value Σ0..1decimalNumerical value (with implicit precision)
.... adjudication 0..*BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
...... coding Σ0..*CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ1..1stringRepresentation defined by the system
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example)
...... coding Σ0..*CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
....... code Σ1..1codeSymbol in syntax defined by the system
..... amount 0..1MoneyMonetary amount
...... value Σ1..1decimalNumerical value (with implicit precision)
...... system ΣI1..1uriSystem that defines coded unit form
...... code Σ1..1codeCoded form of the unit
... totalCost 0..1MoneyTotal Cost of service from the Claim
.... value Σ1..1decimalNumerical value (with implicit precision)
.... system ΣI1..1uriSystem that defines coded unit form
.... code Σ1..1codeCoded form of the unit
... payment 1..1BackboneElementPayment (if paid)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... amount 1..1MoneyPayable amount after adjustment
..... value Σ1..1decimalNumerical value (with implicit precision)
..... system ΣI1..1uriSystem that defines coded unit form

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron