Foundation
Publish-box
(todo)
This
is
the
Continuous
Integration
Build
of
FHIR
(will
be
incorrect/inconsistent
at
times).
See
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Directory
of
published
versions
| Responsible Owner: Financial Management Work Group | Standards Status : Informative | Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson |
ShEx statement for explanationofbenefit
PREFIX fhir: <http://hl7.org/fhir/> PREFIX fhirvs: <http://hl7.org/fhir/ValueSet/> PREFIX xsd: <http://www.w3.org/2001/XMLSchema#> PREFIX rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#>IMPORT <code.shex> IMPORT <date.shex># ShEx Version 2.2 IMPORT <Id.shex> IMPORT <Oid.shex> IMPORT <Uri.shex> IMPORT <Url.shex> IMPORT <Age.shex> IMPORT <Code.shex> IMPORT <Date.shex> IMPORT <Time.shex> IMPORT <Uuid.shex> IMPORT <Meta.shex> IMPORT <Group.shex> IMPORT <Claim.shex> IMPORT <Money.shex> IMPORT <Count.shex> IMPORT <Range.shex> IMPORT <Ratio.shex> IMPORT <String.shex> IMPORT <Period.shex>IMPORT <string.shex>IMPORT <Timing.shex> IMPORT <Coding.shex> IMPORT <Dosage.shex> IMPORT <Device.shex> IMPORT <Patient.shex> IMPORT <Decimal.shex> IMPORT <Address.shex>IMPORT <decimal.shex> IMPORT <boolean.shex> IMPORT <dateTime.shex>IMPORT <Boolean.shex> IMPORT <Instant.shex> IMPORT <Integer.shex> IMPORT <DateTime.shex> IMPORT <Location.shex> IMPORT <Quantity.shex>IMPORT <Resource.shex>IMPORT <Markdown.shex> IMPORT <Distance.shex> IMPORT <Duration.shex> IMPORT <Coverage.shex> IMPORT <Reference.shex>IMPORT <Condition.shex>IMPORT <Procedure.shex> IMPORT <Canonical.shex> IMPORT <Integer64.shex> IMPORT <HumanName.shex> IMPORT <Signature.shex> IMPORT <Condition.shex> IMPORT <Encounter.shex> IMPORT <Identifier.shex> IMPORT <Attachment.shex>IMPORT <positiveInt.shex> IMPORT <unsignedInt.shex>IMPORT <Annotation.shex> IMPORT <RatioRange.shex> IMPORT <Expression.shex> IMPORT <PositiveInt.shex> IMPORT <UnsignedInt.shex> IMPORT <SampledData.shex> IMPORT <Practitioner.shex> IMPORT <Organization.shex> IMPORT <Base64Binary.shex> IMPORT <ContactPoint.shex> IMPORT <UsageContext.shex> IMPORT <Availability.shex> IMPORT <RelatedPerson.shex>IMPORT <ClaimResponse.shex>IMPORT <DeviceRequest.shex>IMPORT <SupplyRequest.shex>IMPORT <ClaimResponse.shex> IMPORT <ContactDetail.shex> IMPORT <DomainResource.shex> IMPORT <ServiceRequest.shex> IMPORT <NutritionOrder.shex> IMPORT <CodeableConcept.shex> IMPORT <BackboneElement.shex> IMPORT <DataRequirement.shex> IMPORT <RelatedArtifact.shex> IMPORT <PractitionerRole.shex> IMPORT <MedicationRequest.shex> IMPORT <CodeableReference.shex> IMPORT <TriggerDefinition.shex> IMPORT <VisionPrescription.shex> IMPORT <ParameterDefinition.shex> IMPORT <VirtualServiceDetail.shex> IMPORT <ExtendedContactDetail.shex> start=@<ExplanationOfBenefit> AND {fhir:nodeRole [fhir:treeRoot]} # Explanation of Benefit resource <ExplanationOfBenefit> EXTENDS @<DomainResource> CLOSED { a [fhir:ExplanationOfBenefit]?;fhir:nodeRole [fhir:treeRoot]?; fhir:identifier @<OneOrMore_Identifier>?; # Business Identifier for the # resource fhir:traceNumber @<OneOrMore_Identifier>?; # Number for trackingfhir:status @<code> ANDfhir:status @<Code> AND {fhir:v @fhirvs:explanationofbenefit-status}; # active | cancelled | draft | # entered-in-error fhir:statusReason @<String>?; # Reason for status change fhir:type @<CodeableConcept>; # Category or discipline fhir:subType @<CodeableConcept>?; # More granular claim typefhir:use @<code> ANDfhir:use @<Code> AND {fhir:v @fhirvs:claim-use}; # claim | preauthorization | # predeterminationfhir:patient @<Reference> AND {fhir:link @<Patient> ? }; # The recipient of the products and # servicesfhir:subject @<Reference> AND {fhir:l @<Group> OR @<Patient> ? }; # The recipient(s) of the products # and services fhir:billablePeriod @<Period>?; # Relevant time frame for the claimfhir:created @<dateTime>; # Response creation date fhir:enterer @<Reference> AND {fhir:linkfhir:created @<DateTime>; # Response creation date fhir:enterer @<Reference> AND {fhir:l @<Patient> OR @<Practitioner> OR @<PractitionerRole> OR @<RelatedPerson> ? }?; # Author of the claimfhir:insurer @<Reference> AND {fhir:linkfhir:insurer @<Reference> AND {fhir:l @<Organization> ? }?; # Party responsible for reimbursementfhir:provider @<Reference> AND {fhir:linkfhir:provider @<Reference> AND {fhir:l @<Organization> OR @<Practitioner> OR @<PractitionerRole> ? }?; # Party responsible for the claim fhir:priority @<CodeableConcept>?; # Desired processing urgency fhir:fundsReserveRequested @<CodeableConcept>?; # For whom to reserve funds fhir:fundsReserve @<CodeableConcept>?; # Funds reserved status fhir:related @<OneOrMore_ExplanationOfBenefit.related>?; # Prior or corollary claimsfhir:prescription @<Reference> AND {fhir:linkfhir:prescription @<Reference> AND {fhir:l @<DeviceRequest> OR @<MedicationRequest> OR @<ServiceRequest> OR @<VisionPrescription> ? }?; # Prescription authorizing services # or productsfhir:originalPrescription @<Reference> AND {fhir:link @<MedicationRequest> ? }?; # Original prescription iffhir:originalPrescription @<Reference> AND {fhir:l @<DeviceRequest> OR @<MedicationRequest> OR @<ServiceRequest> OR @<VisionPrescription> ? }?; # Original prescription if # superceded by fulfiller fhir:event @<OneOrMore_ExplanationOfBenefit.event>?; # Event information fhir:payee @<ExplanationOfBenefit.payee>?; # Recipient of benefits payablefhir:referral @<Reference> AND {fhir:linkfhir:referral @<Reference> AND {fhir:l @<ServiceRequest> ? }?; # Treatment Referral fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the # listed treatmentsfhir:facility @<Reference> AND {fhir:linkfhir:facility @<Reference> AND {fhir:l @<Location> OR @<Organization> ? }?; # Servicing Facilityfhir:claim @<Reference> AND {fhir:linkfhir:claim @<Reference> AND {fhir:l @<Claim> ? }?; # Claim referencefhir:claimResponse @<Reference> AND {fhir:linkfhir:claimResponse @<Reference> AND {fhir:l @<ClaimResponse> ? }?; # Claim response referencefhir:outcome @<code> ANDfhir:outcome @<Code> AND {fhir:v @fhirvs:claim-outcome}; # queued | complete | error | partial fhir:decision @<CodeableConcept>?; # Result of the adjudicationfhir:disposition @<string>?; # Disposition Message fhir:preAuthRef @<OneOrMore_string>?; # Preauthorization referencefhir:disposition @<String>?; # Disposition Message fhir:preAuthRef @<OneOrMore_String>?; # Preauthorization reference fhir:preAuthRefPeriod @<OneOrMore_Period>?; # Preauthorization in-effect period fhir:diagnosisRelatedGroup @<CodeableConcept>?; # Package billing code fhir:careTeam @<OneOrMore_ExplanationOfBenefit.careTeam>?; # Care Team members fhir:supportingInfo @<OneOrMore_ExplanationOfBenefit.supportingInfo>?; # Supporting information fhir:diagnosis @<OneOrMore_ExplanationOfBenefit.diagnosis>?; # Pertinent diagnosis information fhir:procedure @<OneOrMore_ExplanationOfBenefit.procedure>?; # Clinical procedures performedfhir:precedence @<positiveInt>?; # Precedence (primary, secondary,fhir:precedence @<PositiveInt>?; # Precedence (primary, secondary, # etc.) fhir:insurance @<OneOrMore_ExplanationOfBenefit.insurance>?; # Patient insurance information fhir:accident @<ExplanationOfBenefit.accident>?; # Details of the event fhir:patientPaid @<Money>?; # Paid by the patient fhir:item @<OneOrMore_ExplanationOfBenefit.item>?; # Product or service provided fhir:addItem @<OneOrMore_ExplanationOfBenefit.addItem>?; # Insurer added line items fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Header-level adjudication fhir:total @<OneOrMore_ExplanationOfBenefit.total>?; # Adjudication totals fhir:payment @<ExplanationOfBenefit.payment>?; # Payment Details fhir:formCode @<CodeableConcept>?; # Printed form identifier fhir:form @<Attachment>?; # Printed reference or actual form fhir:processNote @<OneOrMore_ExplanationOfBenefit.processNote>?; # Note concerning adjudication fhir:benefitPeriod @<Period>?; # When the benefits are applicable fhir:benefitBalance @<OneOrMore_ExplanationOfBenefit.benefitBalance>?; # Balance by Benefit Category }# Note concerning adjudication <ExplanationOfBenefit.processNote> EXTENDS @<BackboneElement> CLOSED { fhir:number @<positiveInt>?; # Note instance identifier fhir:type @<CodeableConcept>?; # Note purpose fhir:text @<string>?; # Note explanatory text fhir:language @<CodeableConcept>?; # Language of the text } # Anatomical location <ExplanationOfBenefit.item.bodySite> EXTENDS @<BackboneElement> CLOSED { fhir:site @<OneOrMore_CodeableReference>; # Location fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location } # Details of the event <ExplanationOfBenefit.accident> EXTENDS @<BackboneElement> CLOSED { fhir:date @<date>?; # When the incident occurred fhir:type @<CodeableConcept>?; # The nature of the accident fhir:location @<Address> OR (@<Reference> AND {fhir:link @<Location> }) ?; # Where the event occurred } # Additional items <ExplanationOfBenefit.item.detail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Product or service provided fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per item fhir:factor @<decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Detail level adjudication results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Detail level adjudication details fhir:subDetail @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail>?; # Additional items } # Adjudication totals <ExplanationOfBenefit.total> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Type of adjudication information fhir:amount @<Money>; # Financial total for the category }# Payment Details <ExplanationOfBenefit.payment> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>?; # Partial or complete payment fhir:adjustment @<Money>?; # Payment adjustment for non-claim # issues fhir:adjustmentReason @<CodeableConcept>?; # Explanation for the variancefhir:date @<date>?; # Expected date of paymentfhir:date @<Date>?; # Expected date of payment fhir:amount @<Money>?; # Payable amount after adjustment fhir:identifier @<Identifier>?; # Business identifier for the payment }# Insurer added line items <ExplanationOfBenefit.addItem.detail> EXTENDS @<BackboneElement> CLOSED {# Recipient of benefits payable <ExplanationOfBenefit.payee> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>?; # Category of recipient fhir:party @<Reference> AND {fhir:l @<Organization> OR @<Patient> OR @<Practitioner> OR @<PractitionerRole> OR @<RelatedPerson> ? }?; # Recipient reference } # Additional items <ExplanationOfBenefit.item.detail.subDetail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Product or service provided fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per itemfhir:factor @<decimal>?; # Price scaling factorfhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item costfhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem detail level adjudicationfhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Subdetail level adjudication # resultsfhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication fhir:subDetail @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail>?; # Insurer added line itemsfhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Subdetail level adjudication # details } # Note concerning adjudication <ExplanationOfBenefit.processNote> EXTENDS @<BackboneElement> CLOSED { fhir:class @<CodeableConcept>?; # Business kind of note fhir:number @<PositiveInt>?; # Note instance identifier fhir:type @<CodeableConcept>?; # Note purpose fhir:text @<Markdown>?; # Note explanatory text fhir:language @<CodeableConcept>?; # Language of the text } # Product or service provided <ExplanationOfBenefit.item> EXTENDS @<BackboneElement> CLOSED {fhir:sequence @<positiveInt>; # Item instance identifier fhir:careTeamSequence @<OneOrMore_positiveInt>?; # Applicable care team members fhir:diagnosisSequence @<OneOrMore_positiveInt>?; # Applicable diagnoses fhir:procedureSequence @<OneOrMore_positiveInt>?; # Applicable procedures fhir:informationSequence @<OneOrMore_positiveInt>?; # Applicable exception andfhir:sequence @<PositiveInt>; # Item instance identifier fhir:careTeamSequence @<OneOrMore_PositiveInt>?; # Applicable care team members fhir:diagnosisSequence @<OneOrMore_PositiveInt>?; # Applicable diagnoses fhir:procedureSequence @<OneOrMore_PositiveInt>?; # Applicable procedures fhir:informationSequence @<OneOrMore_PositiveInt>?; # Applicable exception and # supporting information fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:subject @<Reference> AND {fhir:l @<Group> OR @<Patient> ? }?; # The recipient of the products and # services fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codesfhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>?; # Request or Referral for Servicefhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription>?; # Request or Referral for Service fhir:modifier @<OneOrMore_CodeableConcept>?; # Product or service billing # modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided underfhir:serviced @<date> ORfhir:serviced @<Date> OR @<Period> ?; # Date or dates of service or # product delivery fhir:location @<CodeableConcept> OR @<Address> OR(@<Reference> AND {fhir:link @<Location> }) ?; # Place of service or where product(@<Reference> AND {fhir:l @<Location> }) ?; # Place of service or where product # was supplied fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per itemfhir:factor @<decimal>?; # Price scaling factorfhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier fhir:bodySite @<OneOrMore_ExplanationOfBenefit.item.bodySite>?; # Anatomical location fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the # listed treatmentsfhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbersfhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Adjudication results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Adjudication details fhir:detail @<OneOrMore_ExplanationOfBenefit.item.detail>?; # Additional items }# Supporting information <ExplanationOfBenefit.supportingInfo> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Information instance identifier fhir:category @<CodeableConcept>; # Classification of the supplied # information fhir:code @<CodeableConcept>?; # Type of information fhir:timing @<date> OR @<Period> ?; # When it occurred fhir:value @<boolean> OR @<string> OR @<Quantity> OR @<Attachment> OR (@<Reference> AND {fhir:link @<Resource> }) OR @<Identifier> ?; # Data to be provided fhir:reason @<Coding>?; # Explanation for the information } # Adjudication details <ExplanationOfBenefit.item.adjudication> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Type of adjudication information fhir:reason @<CodeableConcept>?; # Explanation of adjudication outcome fhir:amount @<Money>?; # Monetary amount fhir:quantity @<Quantity>?; # Non-monitary value# Balance by Benefit Category <ExplanationOfBenefit.benefitBalance> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Benefit classification fhir:excluded @<Boolean>?; # Excluded from the plan fhir:name @<String>?; # Short name for the benefit fhir:description @<String>?; # Description of the benefit or # services covered fhir:network @<CodeableConcept>?; # In or out of network fhir:unit @<CodeableConcept>?; # Individual or family fhir:term @<CodeableConcept>?; # Annual or lifetime fhir:financial @<OneOrMore_ExplanationOfBenefit.benefitBalance.financial>?; # Benefit Summary } # Benefit Summary <ExplanationOfBenefit.benefitBalance.financial> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>; # Benefit classificationfhir:allowed @<unsignedInt> OR @<string> ORfhir:allowed @<UnsignedInt> OR @<String> OR @<Money> ?; # Benefits allowedfhir:used @<unsignedInt> ORfhir:used @<UnsignedInt> OR @<Money> ?; # Benefits used } # Clinical procedures performed <ExplanationOfBenefit.procedure> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Procedure instance identifier fhir:type @<OneOrMore_CodeableConcept>?; # Category of Procedure fhir:date @<DateTime>?; # When the procedure was performed fhir:procedure @<CodeableConcept> OR (@<Reference> AND {fhir:l @<Procedure> }) ; # Specific clinical procedure fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier } # Adjudication totals <ExplanationOfBenefit.total> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Type of adjudication information fhir:amount @<Money>; # Financial total for the category } # Insurer added line items<ExplanationOfBenefit.addItem.detail.subDetail> EXTENDS @<BackboneElement> CLOSED {<ExplanationOfBenefit.addItem.detail> EXTENDS @<BackboneElement> CLOSED { fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per itemfhir:factor @<decimal>?; # Price scaling factorfhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item costfhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem subdetail level # adjudication resultsfhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem detail level adjudication # results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication fhir:subDetail @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail>?; # Insurer added line items }# Care Team members <ExplanationOfBenefit.careTeam> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Order of care team fhir:provider @<Reference> AND {fhir:link @<Organization> OR @<Practitioner> OR @<PractitionerRole> ? }; # Practitioner or organization fhir:responsible @<boolean>?; # Indicator of the lead practitioner fhir:role @<CodeableConcept>?; # Function within the team fhir:specialty @<CodeableConcept>?; # Practitioner or provider # specialization# Supporting information <ExplanationOfBenefit.supportingInfo> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Information instance identifier fhir:category @<CodeableConcept>; # Classification of the supplied # information fhir:code @<CodeableConcept>?; # Type of information fhir:timing @<DateTime> OR @<Period> OR @<Timing> ?; # When it occurred fhir:value @<Base64Binary> OR @<Boolean> OR @<Canonical> OR @<Code> OR @<Date> OR @<DateTime> OR @<Decimal> OR @<Id> OR @<Instant> OR @<Integer> OR @<Integer64> OR @<Markdown> OR @<Oid> OR @<PositiveInt> OR @<String> OR @<Time> OR @<UnsignedInt> OR @<Uri> OR @<Url> OR @<Uuid> OR @<Address> OR @<Age> OR @<Annotation> OR @<Attachment> OR @<CodeableConcept> OR @<CodeableReference> OR @<Coding> OR @<ContactPoint> OR @<Count> OR @<Distance> OR @<Duration> OR @<HumanName> OR @<Identifier> OR @<Money> OR @<Period> OR @<Quantity> OR @<Range> OR @<Ratio> OR @<RatioRange> OR @<Reference> OR @<SampledData> OR @<Signature> OR @<Timing> OR @<ContactDetail> OR @<DataRequirement> OR @<Expression> OR @<ParameterDefinition> OR @<RelatedArtifact> OR @<TriggerDefinition> OR @<UsageContext> OR @<Availability> OR @<ExtendedContactDetail> OR @<VirtualServiceDetail> OR @<Dosage> OR @<Meta> ?; # Data to be provided fhir:reason @<Coding>?; # Explanation for the information }# Balance by Benefit Category <ExplanationOfBenefit.benefitBalance> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Benefit classification fhir:excluded @<boolean>?; # Excluded from the plan fhir:name @<string>?; # Short name for the benefit fhir:description @<string>?; # Description of the benefit or # services covered fhir:network @<CodeableConcept>?; # In or out of network fhir:unit @<CodeableConcept>?; # Individual or family fhir:term @<CodeableConcept>?; # Annual or lifetime fhir:financial @<OneOrMore_ExplanationOfBenefit.benefitBalance.financial>?; # Benefit Summary# Pertinent diagnosis information <ExplanationOfBenefit.diagnosis> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Diagnosis instance identifier fhir:diagnosis @<CodeableConcept> OR (@<Reference> AND {fhir:l @<Condition> }) ; # Nature of illness or problem fhir:type @<OneOrMore_CodeableConcept>?; # Timing or nature of the diagnosis fhir:onAdmission @<CodeableConcept>?; # Present on admission } # Insurer added line items <ExplanationOfBenefit.addItem> EXTENDS @<BackboneElement> CLOSED {fhir:itemSequence @<OneOrMore_positiveInt>?; # Item sequence number fhir:detailSequence @<OneOrMore_positiveInt>?; # Detail sequence number fhir:subDetailSequence @<OneOrMore_positiveInt>?; # Subdetail sequence numberfhir:itemSequence @<OneOrMore_PositiveInt>?; # Item sequence number fhir:detailSequence @<OneOrMore_PositiveInt>?; # Detail sequence number fhir:subDetailSequence @<OneOrMore_PositiveInt>?; # Subdetail sequence number fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:subject @<Reference> AND {fhir:l @<Group> OR @<Patient> ? }?; # The recipient of the products and # services fhir:informationSequence @<OneOrMore_PositiveInt>?; # Applicable exception and # supporting information fhir:provider @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole>?; # Authorized providers fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codesfhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>?; # Request or Referral for Servicefhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription>?; # Request or Referral for Service fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided underfhir:serviced @<date> ORfhir:serviced @<Date> OR @<Period> ?; # Date or dates of service or # product delivery fhir:location @<CodeableConcept> OR @<Address> OR(@<Reference> AND {fhir:link @<Location> }) ?; # Place of service or where product(@<Reference> AND {fhir:l @<Location> }) ?; # Place of service or where product # was supplied fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per itemfhir:factor @<decimal>?; # Price scaling factorfhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:bodySite @<OneOrMore_ExplanationOfBenefit.addItem.bodySite>?; # Anatomical locationfhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbersfhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem level adjudication results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication fhir:detail @<OneOrMore_ExplanationOfBenefit.addItem.detail>?; # Insurer added line items } # Insurer added line items <ExplanationOfBenefit.addItem.detail.subDetail> EXTENDS @<BackboneElement> CLOSED { fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per item fhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem subdetail level # adjudication results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication } # Event information <ExplanationOfBenefit.event> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>; # Specific eventfhir:when @<dateTime> ORfhir:when @<DateTime> OR @<Period> ; # Occurance date or period } # Anatomical location <ExplanationOfBenefit.item.bodySite> EXTENDS @<BackboneElement> CLOSED { fhir:site @<OneOrMore_CodeableReference>; # Location fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location } # Details of the event <ExplanationOfBenefit.accident> EXTENDS @<BackboneElement> CLOSED { fhir:date @<Date>?; # When the incident occurred fhir:type @<CodeableConcept>?; # The nature of the accident fhir:location @<Address> OR (@<Reference> AND {fhir:l @<Location> }) ?; # Where the event occurred } # Prior or corollary claims <ExplanationOfBenefit.related> EXTENDS @<BackboneElement> CLOSED {fhir:claim @<Reference> AND {fhir:link @<Claim> ? }?; # Reference to the related claimfhir:claim @<Reference> AND {fhir:l @<Claim> OR @<ExplanationOfBenefit> ? }?; # Reference to the related claim fhir:relationship @<CodeableConcept>?; # How the reference claim is related fhir:reference @<Identifier>?; # File or case reference } # Patient insurance information <ExplanationOfBenefit.insurance> EXTENDS @<BackboneElement> CLOSED {fhir:focal @<boolean>; # Coverage to be used forfhir:focal @<Boolean>; # Coverage to be used for # adjudicationfhir:coverage @<Reference> AND {fhir:linkfhir:coverage @<Reference> AND {fhir:l @<Coverage> ? }; # Insurance informationfhir:preAuthRef @<OneOrMore_string>?; # Prior authorization referencefhir:preAuthRef @<OneOrMore_String>?; # Prior authorization reference # number }# Pertinent diagnosis information <ExplanationOfBenefit.diagnosis> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Diagnosis instance identifier fhir:diagnosis @<CodeableConcept> OR (@<Reference> AND {fhir:link @<Condition> }) ; # Nature of illness or problem fhir:type @<OneOrMore_CodeableConcept>?; # Timing or nature of the diagnosis fhir:onAdmission @<CodeableConcept>?; # Present on admission } # Anatomical location <ExplanationOfBenefit.addItem.bodySite> EXTENDS @<BackboneElement> CLOSED { fhir:site @<OneOrMore_CodeableReference>; # Location fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location } # Recipient of benefits payable <ExplanationOfBenefit.payee> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>?; # Category of recipient fhir:party @<Reference> AND {fhir:link @<Organization> OR @<Patient> OR @<Practitioner> OR @<PractitionerRole> OR @<RelatedPerson> ? }?; # Recipient reference } # Clinical procedures performed <ExplanationOfBenefit.procedure> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Procedure instance identifier fhir:type @<OneOrMore_CodeableConcept>?; # Category of Procedure fhir:date @<dateTime>?; # When the procedure was performed fhir:procedure @<CodeableConcept> OR (@<Reference> AND {fhir:link @<Procedure> }) ; # Specific clinical procedure fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier } # Adjudication results <ExplanationOfBenefit.item.reviewOutcome> EXTENDS @<BackboneElement> CLOSED { fhir:decision @<CodeableConcept>?; # Result of the adjudication fhir:reason @<OneOrMore_CodeableConcept>?; # Reason for result of the # adjudication fhir:preAuthRef @<string>?; # Preauthorization reference fhir:preAuthPeriod @<Period>?; # Preauthorization reference # effective period }# Additional items<ExplanationOfBenefit.item.detail.subDetail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Product or service provided<ExplanationOfBenefit.item.detail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Product or service provided fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per itemfhir:factor @<decimal>?; # Price scaling factorfhir:factor @<Decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifierfhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Subdetail level adjudication # results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Subdetail level adjudication # detailsfhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Detail level adjudication results fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Detail level adjudication details fhir:subDetail @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail>?; # Additional items } # Care Team members <ExplanationOfBenefit.careTeam> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<PositiveInt>; # Order of care team fhir:provider @<Reference> AND {fhir:l @<Organization> OR @<Practitioner> OR @<PractitionerRole> ? }; # Practitioner or organization fhir:role @<CodeableConcept>?; # Function within the team fhir:specialty @<CodeableConcept>?; # Practitioner or provider # specialization } # Adjudication results <ExplanationOfBenefit.item.reviewOutcome> EXTENDS @<BackboneElement> CLOSED { fhir:decision @<CodeableConcept>?; # Result of the adjudication fhir:reason @<OneOrMore_CodeableConcept>?; # Reason for result of the # adjudication fhir:preAuthRef @<String>?; # Preauthorization reference fhir:preAuthPeriod @<Period>?; # Preauthorization reference # effective period } # Anatomical location <ExplanationOfBenefit.addItem.bodySite> EXTENDS @<BackboneElement> CLOSED { fhir:site @<OneOrMore_CodeableReference>; # Location fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location } # Adjudication details <ExplanationOfBenefit.item.adjudication> EXTENDS @<BackboneElement> CLOSED { fhir:category @<CodeableConcept>; # Type of adjudication information fhir:reason @<CodeableConcept>?; # Explanation of adjudication outcome fhir:amount @<Money>?; # Monetary amount fhir:quantity @<Quantity>?; # Non-monitary value fhir:decisionDate @<DateTime>?; # When was adjudication performed } #---------------------- Cardinality Types (OneOrMore) ------------------- <OneOrMore_Identifier> CLOSED { rdf:first @<Identifier> ; rdf:rest [rdf:nil] OR @<OneOrMore_Identifier> } <OneOrMore_ExplanationOfBenefit.related> CLOSED { rdf:first @<ExplanationOfBenefit.related> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.related> } <OneOrMore_ExplanationOfBenefit.event> CLOSED { rdf:first @<ExplanationOfBenefit.event> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.event> } <OneOrMore_Reference_Encounter> CLOSED {rdf:first @<Reference> AND {fhir:linkrdf:first @<Reference> AND {fhir:l @<Encounter> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Encounter> }<OneOrMore_string> CLOSED { rdf:first @<string> ; rdf:rest [rdf:nil] OR @<OneOrMore_string><OneOrMore_String> CLOSED { rdf:first @<String> ; rdf:rest [rdf:nil] OR @<OneOrMore_String> } <OneOrMore_Period> CLOSED { rdf:first @<Period> ; rdf:rest [rdf:nil] OR @<OneOrMore_Period> } <OneOrMore_ExplanationOfBenefit.careTeam> CLOSED { rdf:first @<ExplanationOfBenefit.careTeam> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.careTeam> } <OneOrMore_ExplanationOfBenefit.supportingInfo> CLOSED { rdf:first @<ExplanationOfBenefit.supportingInfo> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.supportingInfo> } <OneOrMore_ExplanationOfBenefit.diagnosis> CLOSED { rdf:first @<ExplanationOfBenefit.diagnosis> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.diagnosis> } <OneOrMore_ExplanationOfBenefit.procedure> CLOSED { rdf:first @<ExplanationOfBenefit.procedure> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.procedure> } <OneOrMore_ExplanationOfBenefit.insurance> CLOSED { rdf:first @<ExplanationOfBenefit.insurance> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.insurance> } <OneOrMore_ExplanationOfBenefit.item> CLOSED { rdf:first @<ExplanationOfBenefit.item> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item> } <OneOrMore_ExplanationOfBenefit.addItem> CLOSED { rdf:first @<ExplanationOfBenefit.addItem> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem> } <OneOrMore_ExplanationOfBenefit.item.adjudication> CLOSED { rdf:first @<ExplanationOfBenefit.item.adjudication> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.adjudication> } <OneOrMore_ExplanationOfBenefit.total> CLOSED { rdf:first @<ExplanationOfBenefit.total> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.total> } <OneOrMore_ExplanationOfBenefit.processNote> CLOSED { rdf:first @<ExplanationOfBenefit.processNote> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.processNote> } <OneOrMore_ExplanationOfBenefit.benefitBalance> CLOSED { rdf:first @<ExplanationOfBenefit.benefitBalance> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.benefitBalance> }<OneOrMore_CodeableReference> CLOSED { rdf:first @<CodeableReference> ; rdf:rest [rdf:nil] OR @<OneOrMore_CodeableReference> }<OneOrMore_CodeableConcept> CLOSED { rdf:first @<CodeableConcept> ; rdf:rest [rdf:nil] OR @<OneOrMore_CodeableConcept> } <OneOrMore_Reference_Device> CLOSED {rdf:first @<Reference> AND {fhir:linkrdf:first @<Reference> AND {fhir:l @<Device> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Device> }<OneOrMore_positiveInt> CLOSED { rdf:first @<positiveInt> ; rdf:rest [rdf:nil] OR @<OneOrMore_positiveInt> } <OneOrMore_ExplanationOfBenefit.item.detail.subDetail> CLOSED { rdf:first @<ExplanationOfBenefit.item.detail.subDetail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail> } <OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail> CLOSED { rdf:first @<ExplanationOfBenefit.addItem.detail.subDetail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail><OneOrMore_PositiveInt> CLOSED { rdf:first @<PositiveInt> ; rdf:rest [rdf:nil] OR @<OneOrMore_PositiveInt> }<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription> CLOSED { rdf:first @<Reference> AND {fhir:link<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription> CLOSED { rdf:first @<Reference> AND {fhir:l @<DeviceRequest> OR @<MedicationRequest> OR @<NutritionOrder> OR @<ServiceRequest> OR@<SupplyRequest> OR@<VisionPrescription> } ;rdf:rest [rdf:nil] OR @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>rdf:rest [rdf:nil] OR @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription> } <OneOrMore_ExplanationOfBenefit.item.bodySite> CLOSED { rdf:first @<ExplanationOfBenefit.item.bodySite> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.bodySite> } <OneOrMore_ExplanationOfBenefit.item.detail> CLOSED { rdf:first @<ExplanationOfBenefit.item.detail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.detail> } <OneOrMore_ExplanationOfBenefit.benefitBalance.financial> CLOSED { rdf:first @<ExplanationOfBenefit.benefitBalance.financial> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.benefitBalance.financial> } <OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail> CLOSED { rdf:first @<ExplanationOfBenefit.addItem.detail.subDetail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail> } <OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole> CLOSED {rdf:first @<Reference> AND {fhir:linkrdf:first @<Reference> AND {fhir:l @<Organization> OR @<Practitioner> OR @<PractitionerRole> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole> } <OneOrMore_ExplanationOfBenefit.addItem.bodySite> CLOSED { rdf:first @<ExplanationOfBenefit.addItem.bodySite> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.bodySite> } <OneOrMore_ExplanationOfBenefit.addItem.detail> CLOSED { rdf:first @<ExplanationOfBenefit.addItem.detail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.detail> } <OneOrMore_CodeableReference> CLOSED { rdf:first @<CodeableReference> ; rdf:rest [rdf:nil] OR @<OneOrMore_CodeableReference> } <OneOrMore_ExplanationOfBenefit.item.detail.subDetail> CLOSED { rdf:first @<ExplanationOfBenefit.item.detail.subDetail> ; rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail> } #---------------------- Value Sets ------------------------ # This value set includes Claim Processing Outcome codes. fhirvs:claim-outcome ["queued" "complete" "error" "partial"] # The purpose of the Claim: predetermination, preauthorization, claim. fhirvs:claim-use ["claim" "preauthorization" "predetermination"] # A code specifying the state of the resource instance. fhirvs:explanationofbenefit-status ["active" "cancelled" "draft" "entered-in-error"]
Usage note: every effort has been made to ensure that the ShEx files are correct and useful, but they are not a normative part of the specification.
FHIR
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HL7.org
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FHIR
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Tue,
Apr
1,
Mon,
Nov
10,
2025
12:25+1100.
15:22+0000.
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