Blue Button 2.0 Implementation Guide

SD.1 StructureDefinition-bluebutton-pde-claim

This profile sets minimum expectations for the ExplanationOfBenefit PDE resource to record, search and fetch basic demographics and other administrative information about an individual Part D Event. 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 Part D Event 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 PDE must have:

  1. an id
  2. EOB identifiers (e.g. PDE_ID, ClaimGroup, RX_SRVC_RFRNC_NUM)
  3. a status
  4. a type
  5. a patient
  6. a disposition
  7. information
  8. a care team
  9. an insurance
  10. an item

If the data is available a Patient shall include:

  1. an organization
  2. a facility
  3. a payment

Profile specific implementation guidance:

  • none

Examples

SD.1.1 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-pde-claim.html

Published on Tue Feb 20 00:00:00 UTC 2018 as a draft by CMS Blue Button 2.0 Team.

This profile builds on ExplanationOfBenefit

Complete Summary of the Mandatory Requirements

  1. An id in ExplanationOfBenefit.id

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

  3. One status in ExplanationOfBenefit.status

  4. One type in ExplanationOfBenefit.type
    • an ExplanationOfBenefit.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  5. One patient in ExplanationOfBenefit.patient
    • an ExplanationOfBenefit.patient must have:
      • a patient.reference
  6. One type in ExplanationOfBenefit.disposition
    • an ExplanationOfBenefit.disposition must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  7. One or more … 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
  8. One 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
  9. One insurance in ExplanationOfBenefit.insurance
    • an ExplanationOfBenefit.insurance must have:
      • a insurance.coverage, and each coverage must have: - a coverage.reference - a coverage.planConctractId - a coverage.planBenefitPackageId
  10. One item in ExplanationOfBenefit.item
    • an ExplanationOfBenefit.item must have:
      • an item.sequence
      • an item.service, and each service must have:
        • a service.coding, and each coding must have: - a coding.system - a coding.code
      • an item.serviced
      • an item.quantity, and each quantity must have:
        • a quantity.value
        • a quantity.fillNum
        • a quantity.daysSupplyNum
      • 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.amount, and each amount must have: - a amount.value - a amount.system - a amount.code
      • an item.detail, and each detail must have:
        • a detail.sequence
        • a detail.type, and each type must have:
          • a type.coding, and each coding must have: - a coding.system - a coding.code

Summary of the Must Support Requirements

Additionally your system must support:

  1. An organization in ExplanationOfBenefit.organization
    • an ExplanationOfBenefit.organization must have:
      • an organization.identifier
  2. A facility in ExplanationOfBenefit.facility
    • an ExplanationOfBenefit.facility must have:
      • a facility.identifier
      • a facility.phrmcySrvcTypeCd
  3. A payment in ExplanationOfBenefit.payment
    • an ExplanationOfBenefit.payment must have:
      • a payment.date
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id S1..
... identifier S1..
.... id ..0
.... use ..0
.... type ..0
.... system S1..
.... value S1..
.... period ..0
.... assigner ..0
... status S1..
... type S1..
.... id ..0
.... coding S1..
..... id ..0
..... system S1..
..... version ..0
..... code S1..
..... display ..0
..... userSelected ..0
.... text ..0
... subType ..0
... patient S1..
.... id ..0
.... reference S1..
.... identifier ..0
.... display ..0
... billablePeriod ..0
... created ..0
... enterer ..0
... insurer ..0
... provider ..0
... referral ..0
... claim ..0
... claimResponse ..0
... outcome ..0
... disposition S1..
... related ..0
... prescription ..0
... originalPrescription ..0
... payee ..0
... information S1..
.... id ..0
.... sequence S
.... category S
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... code ..0
.... timing[x] ..0
.... value[x] ..0
.... reason ..0
... careTeam S1..1
.... id ..0
.... sequence S
.... provider S
..... id ..0
..... reference ..0
..... identifier S1..
..... display ..0
.... responsible ..0
.... role S1..
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... qualification ..0
... diagnosis ..0
... procedure ..0
... precedence ..0
... insurance S1..
.... id ..0
.... coverage S1..
..... id ..0
..... reference S1..
..... identifier ..0
..... display ..0
..... bluebutton-pde-plan-cntrct-rec-id-extension 1..1IdentifierOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension
Binding: Plan Contract ID (required)
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension"
...... valueIdentifier 1..Identifier
....... use ..0
....... type ..0
....... system 1..
....... value 1..
....... period ..0
....... assigner ..0
..... bluebutton-pde-benefit-package-id-extension 1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension"
...... valueIdentifier 1..Identifier
....... use ..0
....... type ..0
....... system 1..
....... value 1..
....... period ..0
....... assigner ..0
.... preAuthRef ..0
... accident ..0
... employmentImpacted ..0
... hospitalization ..0
... item S1..1
.... id ..0
.... sequence S
.... careTeamLinkId ..1
.... diagnosisLinkId ..0
.... procedureLinkId ..0
.... informationLinkId ..0
.... revenue ..0
.... category ..0
.... service S1..
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... modifier ..0
.... programCode ..0
.... serviced[x] S1..
.... location[x] ..0
.... quantity S1..
..... id ..0
..... value S1..
..... unit ..0
..... system ..0
..... code ..0
..... bluebutton-pde-fill-num-extension S1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension"
...... valueString S1..string
..... bluebutton-pde-days-supply-num-extension S1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension"
...... valueString S1..string
.... unitPrice ..0
.... factor ..0
.... net ..0
.... udi ..0
.... bodySite ..0
.... subSite ..0
.... encounter ..0
.... noteNumber ..0
.... adjudication S1..
..... id ..0
..... category S
...... id ..0
...... coding S1..1
....... id ..0
....... system S1..
....... version ..0
....... code S1..
....... display ..0
....... userSelected ..0
...... text ..0
..... reason ..0
..... amount S1..
...... id ..0
...... value S1..
...... comparator ..0
...... unit ..0
...... system S1..
...... code S1..
..... value ..0
.... detail S1..1
..... id ..0
..... type S
...... id ..0
...... coding S1..1
....... id ..0
....... system S1..
....... version ..0
....... code S1..
....... display ..0
....... userSelected ..0
...... text ..0
..... revenue ..0
..... category ..0
..... service ..0
..... modifier ..0
..... programCode ..0
..... quantity ..0
..... unitPrice ..0
..... factor ..0
..... net ..0
..... udi ..0
..... noteNumber ..0
..... adjudication ..0
..... subDetail ..0
... addItem ..0
... totalCost ..0
... unallocdeductible ..0
... totalBenefit ..0
... form ..0
... processNote ..0
... benefitBalance ..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id SΣ1..1idLogical id of this artifact
... identifier S1..*IdentifierBusiness Identifier
.... system SΣ1..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 SΣ1..1stringThe value that is unique
Example General': 123456
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type S1..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
.... coding SΣ1..*CodingCode defined by a terminology system
..... system SΣ1..1uriIdentity of the terminology system
..... code SΣ1..1codeSymbol in syntax defined by the system
... patient S1..1Reference(Patient)The subject of the Products and Services
.... reference SΣ1..1stringLiteral reference, Relative, internal or absolute URL
... organization 0..1Reference(Organization)Responsible organization for the claim
.... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
... facility 0..1Reference(Location)Servicing Facility
.... bluebutton-pde-phrmcy-srvc-type-cd-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-phrmcy-srvc-type-cd-extension
Binding: Pharmacy service type code (required)
..... id 0..1stringxml:id (or equivalent in JSON)
..... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-phrmcy-srvc-type-cd-extension"
..... valueCode S1..1codeValue of extension
.... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
... disposition S1..1stringDisposition Message
... information S1..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
Binding: Information Categories (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntInformation instance identifier
.... category S1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
... careTeam S1..1BackboneElementCare Team members
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntNumber to covey order of careteam
.... provider S1..1Reference(Practitioner), Reference(Organization)Member of the Care Team
..... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
.... role S1..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
... insurance S1..1BackboneElementInsurance or medical plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage S1..1Reference(Coverage)Insurance information
..... bluebutton-pde-plan-cntrct-rec-id-extension 1..1IdentifierOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension
Binding: Plan Contract ID (required)
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension"
...... valueIdentifier 1..1IdentifierValue of extension
....... id 0..1stringxml:id (or equivalent in JSON)
....... 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
..... bluebutton-pde-benefit-package-id-extension 1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension"
...... valueIdentifier 1..1IdentifierValue of extension
....... id 0..1stringxml:id (or equivalent in JSON)
....... 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
..... reference SΣ1..1stringLiteral reference, Relative, internal or absolute URL
... item S1..1BackboneElementGoods and Services
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
.... careTeamLinkId 0..1positiveIntApplicable careteam members
.... service S1..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... quantity S1..1SimpleQuantityCount of Products or Services
..... bluebutton-pde-fill-num-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension"
...... valueString S1..1stringValue of extension
..... bluebutton-pde-days-supply-num-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension"
...... valueString S1..1stringValue of extension
..... value SΣ1..1decimalNumerical value (with implicit precision)
.... adjudication S1..*BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category S1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
...... coding SΣ1..1CodingCode defined by a terminology system
....... system SΣ1..1uriIdentity of the terminology system
....... code SΣ1..1codeSymbol in syntax defined by the system
..... amount S1..1MoneyMonetary amount
...... value SΣ1..1decimalNumerical value (with implicit precision)
...... system SΣ1..1uriSystem that defines coded unit form
...... code SΣ1..1codeCoded form of the unit
.... detail S1..1BackboneElementAdditional items
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type S1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required)
...... coding SΣ1..1CodingCode defined by a terminology system
....... system SΣ1..1uriIdentity of the terminology system
....... code SΣ1..1codeSymbol in syntax defined by the system
... payment 0..1BackboneElementPayment (if paid)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date S1..1dateExpected date of Payment

doco Documentation for this format

Complete Summary of the Mandatory Requirements

  1. An id in ExplanationOfBenefit.id

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

  3. One status in ExplanationOfBenefit.status

  4. One type in ExplanationOfBenefit.type
    • an ExplanationOfBenefit.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  5. One patient in ExplanationOfBenefit.patient
    • an ExplanationOfBenefit.patient must have:
      • a patient.reference
  6. One type in ExplanationOfBenefit.disposition
    • an ExplanationOfBenefit.disposition must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  7. One or more … 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
  8. One 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
  9. One insurance in ExplanationOfBenefit.insurance
    • an ExplanationOfBenefit.insurance must have:
      • a insurance.coverage, and each coverage must have: - a coverage.reference - a coverage.planConctractId - a coverage.planBenefitPackageId
  10. One item in ExplanationOfBenefit.item
    • an ExplanationOfBenefit.item must have:
      • an item.sequence
      • an item.service, and each service must have:
        • a service.coding, and each coding must have: - a coding.system - a coding.code
      • an item.serviced
      • an item.quantity, and each quantity must have:
        • a quantity.value
        • a quantity.fillNum
        • a quantity.daysSupplyNum
      • 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.amount, and each amount must have: - a amount.value - a amount.system - a amount.code
      • an item.detail, and each detail must have:
        • a detail.sequence
        • a detail.type, and each type must have:
          • a type.coding, and each coding must have: - a coding.system - a coding.code

Summary of the Must Support Requirements

Additionally your system must support:

  1. An organization in ExplanationOfBenefit.organization
    • an ExplanationOfBenefit.organization must have:
      • an organization.identifier
  2. A facility in ExplanationOfBenefit.facility
    • an ExplanationOfBenefit.facility must have:
      • a facility.identifier
      • a facility.phrmcySrvcTypeCd
  3. A payment in ExplanationOfBenefit.payment
    • an ExplanationOfBenefit.payment must have:
      • a payment.date

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id S1..
... identifier S1..
.... id ..0
.... use ..0
.... type ..0
.... system S1..
.... value S1..
.... period ..0
.... assigner ..0
... status S1..
... type S1..
.... id ..0
.... coding S1..
..... id ..0
..... system S1..
..... version ..0
..... code S1..
..... display ..0
..... userSelected ..0
.... text ..0
... subType ..0
... patient S1..
.... id ..0
.... reference S1..
.... identifier ..0
.... display ..0
... billablePeriod ..0
... created ..0
... enterer ..0
... insurer ..0
... provider ..0
... referral ..0
... claim ..0
... claimResponse ..0
... outcome ..0
... disposition S1..
... related ..0
... prescription ..0
... originalPrescription ..0
... payee ..0
... information S1..
.... id ..0
.... sequence S
.... category S
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... code ..0
.... timing[x] ..0
.... value[x] ..0
.... reason ..0
... careTeam S1..1
.... id ..0
.... sequence S
.... provider S
..... id ..0
..... reference ..0
..... identifier S1..
..... display ..0
.... responsible ..0
.... role S1..
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... qualification ..0
... diagnosis ..0
... procedure ..0
... precedence ..0
... insurance S1..
.... id ..0
.... coverage S1..
..... id ..0
..... reference S1..
..... identifier ..0
..... display ..0
..... bluebutton-pde-plan-cntrct-rec-id-extension 1..1IdentifierOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension
Binding: Plan Contract ID (required)
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension"
...... valueIdentifier 1..Identifier
....... use ..0
....... type ..0
....... system 1..
....... value 1..
....... period ..0
....... assigner ..0
..... bluebutton-pde-benefit-package-id-extension 1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension"
...... valueIdentifier 1..Identifier
....... use ..0
....... type ..0
....... system 1..
....... value 1..
....... period ..0
....... assigner ..0
.... preAuthRef ..0
... accident ..0
... employmentImpacted ..0
... hospitalization ..0
... item S1..1
.... id ..0
.... sequence S
.... careTeamLinkId ..1
.... diagnosisLinkId ..0
.... procedureLinkId ..0
.... informationLinkId ..0
.... revenue ..0
.... category ..0
.... service S1..
..... id ..0
..... coding S1..1
...... id ..0
...... system S1..
...... version ..0
...... code S1..
...... display ..0
...... userSelected ..0
..... text ..0
.... modifier ..0
.... programCode ..0
.... serviced[x] S1..
.... location[x] ..0
.... quantity S1..
..... id ..0
..... value S1..
..... unit ..0
..... system ..0
..... code ..0
..... bluebutton-pde-fill-num-extension S1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension"
...... valueString S1..string
..... bluebutton-pde-days-supply-num-extension S1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension
...... url "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension"
...... valueString S1..string
.... unitPrice ..0
.... factor ..0
.... net ..0
.... udi ..0
.... bodySite ..0
.... subSite ..0
.... encounter ..0
.... noteNumber ..0
.... adjudication S1..
..... id ..0
..... category S
...... id ..0
...... coding S1..1
....... id ..0
....... system S1..
....... version ..0
....... code S1..
....... display ..0
....... userSelected ..0
...... text ..0
..... reason ..0
..... amount S1..
...... id ..0
...... value S1..
...... comparator ..0
...... unit ..0
...... system S1..
...... code S1..
..... value ..0
.... detail S1..1
..... id ..0
..... type S
...... id ..0
...... coding S1..1
....... id ..0
....... system S1..
....... version ..0
....... code S1..
....... display ..0
....... userSelected ..0
...... text ..0
..... revenue ..0
..... category ..0
..... service ..0
..... modifier ..0
..... programCode ..0
..... quantity ..0
..... unitPrice ..0
..... factor ..0
..... net ..0
..... udi ..0
..... noteNumber ..0
..... adjudication ..0
..... subDetail ..0
... addItem ..0
... totalCost ..0
... unallocdeductible ..0
... totalBenefit ..0
... form ..0
... processNote ..0
... benefitBalance ..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*Explanation of Benefit resource
... id SΣ1..1idLogical id of this artifact
... identifier S1..*IdentifierBusiness Identifier
.... system SΣ1..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 SΣ1..1stringThe value that is unique
Example General': 123456
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type S1..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required)
.... coding SΣ1..*CodingCode defined by a terminology system
..... system SΣ1..1uriIdentity of the terminology system
..... code SΣ1..1codeSymbol in syntax defined by the system
... patient S1..1Reference(Patient)The subject of the Products and Services
.... reference SΣ1..1stringLiteral reference, Relative, internal or absolute URL
... organization 0..1Reference(Organization)Responsible organization for the claim
.... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
... facility 0..1Reference(Location)Servicing Facility
.... bluebutton-pde-phrmcy-srvc-type-cd-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-phrmcy-srvc-type-cd-extension
Binding: Pharmacy service type code (required)
..... id 0..1stringxml:id (or equivalent in JSON)
..... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-phrmcy-srvc-type-cd-extension"
..... valueCode S1..1codeValue of extension
.... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
... disposition S1..1stringDisposition Message
... information S1..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
Binding: Information Categories (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntInformation instance identifier
.... category S1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
... careTeam S1..1BackboneElementCare Team members
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntNumber to covey order of careteam
.... provider S1..1Reference(Practitioner), Reference(Organization)Member of the Care Team
..... identifier SΣ1..1IdentifierLogical reference, when literal reference is not known
.... role S1..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
... insurance S1..1BackboneElementInsurance or medical plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage S1..1Reference(Coverage)Insurance information
..... bluebutton-pde-plan-cntrct-rec-id-extension 1..1IdentifierOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension
Binding: Plan Contract ID (required)
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-plan-cntrct-rec-id-extension"
...... valueIdentifier 1..1IdentifierValue of extension
....... id 0..1stringxml:id (or equivalent in JSON)
....... 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
..... bluebutton-pde-benefit-package-id-extension 1..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-benefit-package-id-extension"
...... valueIdentifier 1..1IdentifierValue of extension
....... id 0..1stringxml:id (or equivalent in JSON)
....... 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
..... reference SΣ1..1stringLiteral reference, Relative, internal or absolute URL
... item S1..1BackboneElementGoods and Services
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
.... careTeamLinkId 0..1positiveIntApplicable careteam members
.... service S1..1CodeableConceptBilling Code
Binding: USCLS Codes (example)
..... coding SΣ1..1CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
...... code SΣ1..1codeSymbol in syntax defined by the system
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... quantity S1..1SimpleQuantityCount of Products or Services
..... bluebutton-pde-fill-num-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-fill-num-extension"
...... valueString S1..1stringValue of extension
..... bluebutton-pde-days-supply-num-extension S1..1CodingAdditional Content defined by implementations
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension
...... id 0..1stringxml:id (or equivalent in JSON)
...... url 1..1uri"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-pde-days-supply-num-extension"
...... valueString S1..1stringValue of extension
..... value SΣ1..1decimalNumerical value (with implicit precision)
.... adjudication S1..*BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category S1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example)
...... coding SΣ1..1CodingCode defined by a terminology system
....... system SΣ1..1uriIdentity of the terminology system
....... code SΣ1..1codeSymbol in syntax defined by the system
..... amount S1..1MoneyMonetary amount
...... value SΣ1..1decimalNumerical value (with implicit precision)
...... system SΣ1..1uriSystem that defines coded unit form
...... code SΣ1..1codeCoded form of the unit
.... detail S1..1BackboneElementAdditional items
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type S1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required)
...... coding SΣ1..1CodingCode defined by a terminology system
....... system SΣ1..1uriIdentity of the terminology system
....... code SΣ1..1codeSymbol in syntax defined by the system
... payment 0..1BackboneElementPayment (if paid)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date S1..1dateExpected date of Payment

doco Documentation for this format

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