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13.10 Resource ExplanationOfBenefit - Content

Financial Management Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.

This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.

Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. It may also be used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. An EOB will never be created for patient or subscriber information exchange if an error was detected in the Claim.

It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. When the resource was originally being developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource for multiple purposes.

Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if the payee is the provider as that would leak business confidential information.

Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. Only the ClaimResponse contains the appropriate adjudication information for a payor response to a Claim.

The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining EOBs: EOBs may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.

The eClaim domain includes a number of related resources
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
ProcessPriority (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
FundsReserve (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
FundsReserve (Example)
... related 0..*BackboneElementPrior or corollary claims
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
PayeeType (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
V3 Value SetActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*see adjudicationAdded items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationAdded items adjudication
... adjudication 0..*see adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Forms (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Common Languages (Preferred but limited to AllLanguages)
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)A unique identifier assigned to this explanation of benefitidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)ExplanationOfBenefitStatus! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the futureuse : code [1..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is soughtpatient : Reference [1..1] « Patient »The period for which charges are being submittedbillablePeriod : Period [0..1]The date this resource was createdcreated : dateTime [1..1]Individual who created the claim, predetermination or preauthorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The party responsible for authorization, adjudication and reimbursementinsurer : Reference [1..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, routine deferredpriority : CodeableConcept [0..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example)ProcessPriority?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserveRequested : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of pharmacy, device or vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « MedicationRequest »A reference to a referral resourcereferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The business identifier for the instance of the adjudication request: claim predetermination or preauthorizationclaim : Reference [0..1] « Claim »The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization responseclaimResponse : Reference [0..1] « ClaimResponse »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « The result of the claim processing. (Strength=Required)ClaimProcessingCodes! »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..*]The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as providedpreAuthRefPeriod : Period [0..*]This indicates the relative order of a series of EOBs related to different coverages for the same suite of servicesprecedence : positiveInt [0..1]A code for the form to be used for printing the contentformCode : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]RelatedClaimReference to a related claimclaim : Reference [0..1] « Claim »A code to convey how the claims are relatedrelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertainsreference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamA number to uniquely identify care team entriessequence : positiveInt [1..1]Member of the team who provided the product or serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and/or responsible for the claimed products or servicesresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)ClaimCareTeamRoleCodes?? »The qualification of the practitioner which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC...?? »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is soughtcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « boolean|string|Quantity|Attachment| Reference(Any) »Provides the reason in the situation where a reason code is required in addition to the contentreason : Coding [0..1] « Reason codes for the missing teeth. (Strength=Example)MissingToothReasonCodes?? »DiagnosisA number to uniquely identify diagnosis entriessequence : positiveInt [1..1]The nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example)ExampleProcedureTypeCodes?? »Date and optionally time the procedure was performeddate : dateTime [0..1]The code or reference to a Procedure resource which identifies the clinical intervention performedprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes?? »Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »InsuranceA flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorizationpreAuthRef : string [0..*]AccidentDate of an accident event related to the products and services contained in the claimdate : date [0..1]The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurerstype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)v3.ActIncidentCode+ »The physical location of the accident eventlocation[x] : Type [0..1] « Address|Reference(Location) »ItemA number to uniquely identify item entriessequence : positiveInt [1..1]Care team members related to this service or productcareTeamSequence : positiveInt [0..*]Diagnoses applicable for this service or productdiagnosisSequence : positiveInt [0..*]Procedures applicable for this service or productprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or productinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the product or service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place where the service is rendered. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AdjudicationA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « Adjudication reason codes. (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]SubDetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details woithin the details within the claim item which this line is intended to replacesubDetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the product or service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place where the service is rendered. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemDetailSubDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]TotalA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [0..1] « The type (partial, complete) of the payment. (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits payable less any payment adjustmentamount : Money [0..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the note texttype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The explanation or description associated with the processingtext : string [0..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « A human language. (Strength=Preferred)CommonLanguages? »BenefitBalanceCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)BenefitCategoryCodes?? »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)BenefitTermCodes?? »BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : Type [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : Type [0..1] « unsignedInt|Money »Other claims which are related to this claim such as prior submissions or claims for related services or for the same eventrelated[0..*]The party to be reimbursed for cost of the products and services according to the terms of the policypayee[0..1]The members of the team who provided the products and servicescareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Information about diagnoses relevant to the claim itemsdiagnosis[0..*]Procedures performed on the patient relevant to the billing items with the claimprocedure[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[1..*]Details of a accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this itemadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]Third-tier of goods and servicessubDetail[0..*]Second-tier of goods and servicesdetail[0..*]A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-detailsitem[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[0..*]Benefits Used to datefinancial[0..*]Balance by Benefit CategorybenefitBalance[0..*]

XML Template

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for the resource --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author of the claim --></enterer>
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency  --></priority>
 <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference -->
 <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|Organization) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <qualification><!-- 0..1 CodeableConcept Practitioner credential or specialization --></qualification>
 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Data to be provided --></value[x]>
  <reason><!-- 0..1 Coding Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 1..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitary value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit classification --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Benefit classification --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for the resource
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Response creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency 
  "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // Category of recipient
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : ["<string>"], // Preauthorization reference
  "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { Coding } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : [{ // R!  Patient insurance information
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "preAuthRef" : ["<string>"] // Prior authorization reference number
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable care team members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitary value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Product or service provided
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Product or service provided
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }], // Unique device identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the variance
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "benefitPeriod" : { Period }, // When the benefits are applicable
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit classification
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Benefit classification
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      "usedUnsignedInt" : "<unsignedInt>"
      "usedMoney" : { Money }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier for the resource
  fhir:ExplanationOfBenefit.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ExplanationOfBenefit.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 1..1 Response creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author of the claim
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ExplanationOfBenefit.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 1..1 Party responsible for the claim
  fhir:ExplanationOfBenefit.priority [ CodeableConcept ]; # 0..1 Desired processing urgency
  fhir:ExplanationOfBenefit.fundsReserveRequested [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:ExplanationOfBenefit.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ExplanationOfBenefit.related [ # 0..* Prior or corollary claims
    fhir:ExplanationOfBenefit.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:ExplanationOfBenefit.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 File or case reference
  ], ...;
  fhir:ExplanationOfBenefit.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services or products
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superceded by fulfiller
  fhir:ExplanationOfBenefit.payee [ # 0..1 Recipient of benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Category of recipient
    fhir:ExplanationOfBenefit.payee.party [ Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) ]; # 0..1 Recipient reference
  ];
  fhir:ExplanationOfBenefit.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment Referral
  fhir:ExplanationOfBenefit.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:ExplanationOfBenefit.claim [ Reference(Claim) ]; # 0..1 Claim reference
  fhir:ExplanationOfBenefit.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Claim response reference
  fhir:ExplanationOfBenefit.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.preAuthRef [ string ], ... ; # 0..* Preauthorization reference
  fhir:ExplanationOfBenefit.preAuthRefPeriod [ Period ], ... ; # 0..* Preauthorization in-effect period
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 1..1 Practitioner or organization
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:ExplanationOfBenefit.careTeam.qualification [ CodeableConcept ]; # 0..1 Practitioner credential or specialization
  ], ...;
  fhir:ExplanationOfBenefit.supportingInfo [ # 0..* Supporting information
    fhir:ExplanationOfBenefit.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:ExplanationOfBenefit.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.supportingInfo.timingDate [ date ]
      fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [ Period ]
    # ExplanationOfBenefit.supportingInfo.value[x] : 0..1 Data to be provided. One of these 5
      fhir:ExplanationOfBenefit.supportingInfo.valueBoolean [ boolean ]
      fhir:ExplanationOfBenefit.supportingInfo.valueString [ string ]
      fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.supportingInfo.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.supportingInfo.valueReference [ Reference(Any) ]
    fhir:ExplanationOfBenefit.supportingInfo.reason [ Coding ]; # 0..1 Explanation for the information
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:ExplanationOfBenefit.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:ExplanationOfBenefit.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Clinical procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:ExplanationOfBenefit.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
    fhir:ExplanationOfBenefit.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 1..* Patient insurance information
    fhir:ExplanationOfBenefit.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
  ], ...;
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of the event
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the incident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.item [ # 0..* Product or service provided
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:ExplanationOfBenefit.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable care team members
    fhir:ExplanationOfBenefit.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:ExplanationOfBenefit.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:ExplanationOfBenefit.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:ExplanationOfBenefit.item.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:ExplanationOfBenefit.item.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ExplanationOfBenefit.item.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ExplanationOfBenefit.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ExplanationOfBenefit.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitary value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Product or service provided
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:ExplanationOfBenefit.item.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Product or service provided
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:ExplanationOfBenefit.item.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ExplanationOfBenefit.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ExplanationOfBenefit.addItem.subDetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ExplanationOfBenefit.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ExplanationOfBenefit.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.addItem.servicedDate [ date ]
      fhir:ExplanationOfBenefit.addItem.servicedPeriod [ Period ]
    # ExplanationOfBenefit.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.addItem.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.addItem.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ExplanationOfBenefit.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ExplanationOfBenefit.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ExplanationOfBenefit.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Insurer added line items
      fhir:ExplanationOfBenefit.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ExplanationOfBenefit.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ExplanationOfBenefit.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      fhir:ExplanationOfBenefit.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ExplanationOfBenefit.total [ # 0..* Adjudication totals
    fhir:ExplanationOfBenefit.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ExplanationOfBenefit.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment Details
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or complete payment
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the variance
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ExplanationOfBenefit.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ExplanationOfBenefit.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ExplanationOfBenefit.processNote [ # 0..* Note concerning adjudication
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ExplanationOfBenefit.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ExplanationOfBenefit.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit classification
    fhir:ExplanationOfBenefit.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
    fhir:ExplanationOfBenefit.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Benefit classification
      # ExplanationOfBenefit.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since R3

ExplanationOfBenefit
ExplanationOfBenefit.status
  • Min Cardinality changed from 0 to 1
  • Change value set from http://hl7.org/fhir/ValueSet/explanationofbenefit-status to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.0
ExplanationOfBenefit.type
  • Min Cardinality changed from 0 to 1
  • Change binding strength from required to extensible
ExplanationOfBenefit.subType
  • Max Cardinality changed from * to 1
ExplanationOfBenefit.use
  • Added Mandatory Element
ExplanationOfBenefit.patient
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.created
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.enterer
  • Type Reference: Added Target Type PractitionerRole
ExplanationOfBenefit.insurer
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.provider
  • Min Cardinality changed from 0 to 1
  • Type Reference: Added Target Types PractitionerRole, Organization
ExplanationOfBenefit.priority
  • Added Element
ExplanationOfBenefit.fundsReserveRequested
  • Added Element
ExplanationOfBenefit.fundsReserve
  • Added Element
ExplanationOfBenefit.payee.party
  • Type Reference: Added Target Type PractitionerRole
ExplanationOfBenefit.referral
  • Type Reference: Added Target Type ServiceRequest
  • Type Reference: Removed Target Type ReferralRequest
ExplanationOfBenefit.outcome
  • Min Cardinality changed from 0 to 1
  • Type changed from CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 (required)
ExplanationOfBenefit.preAuthRef
  • Added Element
ExplanationOfBenefit.preAuthRefPeriod
  • Added Element
ExplanationOfBenefit.careTeam.provider
  • Type Reference: Added Target Type PractitionerRole
ExplanationOfBenefit.supportingInfo
  • Renamed from information to supportingInfo
ExplanationOfBenefit.supportingInfo.sequence
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
ExplanationOfBenefit.supportingInfo.category
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
ExplanationOfBenefit.supportingInfo.code
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
ExplanationOfBenefit.supportingInfo.timing[x]
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
ExplanationOfBenefit.supportingInfo.value[x]
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
  • Add Type boolean
ExplanationOfBenefit.supportingInfo.reason
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo
ExplanationOfBenefit.diagnosis.onAdmission
  • Added Element
ExplanationOfBenefit.procedure.type
  • Added Element
ExplanationOfBenefit.procedure.udi
  • Added Element
ExplanationOfBenefit.insurance
  • Min Cardinality changed from 0 to 1
  • Max Cardinality changed from 1 to *
ExplanationOfBenefit.insurance.focal
  • Added Mandatory Element
ExplanationOfBenefit.insurance.coverage
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.accident.type
  • Change binding strength from required to extensible
ExplanationOfBenefit.item.careTeamSequence
  • Renamed from careTeamLinkId to careTeamSequence
ExplanationOfBenefit.item.diagnosisSequence
  • Renamed from diagnosisLinkId to diagnosisSequence
ExplanationOfBenefit.item.procedureSequence
  • Renamed from procedureLinkId to procedureSequence
ExplanationOfBenefit.item.informationSequence
  • Renamed from informationLinkId to informationSequence
ExplanationOfBenefit.item.productOrService
  • Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.item.detail.productOrService
  • Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.addItem.itemSequence
  • Renamed from sequenceLinkId to itemSequence
ExplanationOfBenefit.addItem.detailSequence
  • Added Element
ExplanationOfBenefit.addItem.subDetailSequence
  • Added Element
ExplanationOfBenefit.addItem.provider
  • Added Element
ExplanationOfBenefit.addItem.productOrService
  • Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.addItem.programCode
  • Added Element
ExplanationOfBenefit.addItem.serviced[x]
  • Added Element
ExplanationOfBenefit.addItem.location[x]
  • Added Element
ExplanationOfBenefit.addItem.quantity
  • Added Element
ExplanationOfBenefit.addItem.unitPrice
  • Added Element
ExplanationOfBenefit.addItem.factor
  • Added Element
ExplanationOfBenefit.addItem.net
  • Renamed from fee to net
ExplanationOfBenefit.addItem.bodySite
  • Added Element
ExplanationOfBenefit.addItem.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.productOrService
  • Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.addItem.detail.quantity
  • Added Element
ExplanationOfBenefit.addItem.detail.unitPrice
  • Added Element
ExplanationOfBenefit.addItem.detail.factor
  • Added Element
ExplanationOfBenefit.addItem.detail.net
  • Renamed from fee to net
ExplanationOfBenefit.addItem.detail.subDetail
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Added Mandatory Element
ExplanationOfBenefit.addItem.detail.subDetail.modifier
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.quantity
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.factor
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.net
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.adjudication
  • Added Element
ExplanationOfBenefit.adjudication
  • Added Element
ExplanationOfBenefit.total
  • Added Element
ExplanationOfBenefit.total.category
  • Added Mandatory Element
ExplanationOfBenefit.total.amount
  • Added Mandatory Element
ExplanationOfBenefit.formCode
  • Added Element
ExplanationOfBenefit.form
  • Type changed from CodeableConcept to Attachment
ExplanationOfBenefit.processNote.type
  • Type changed from CodeableConcept to code
  • Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.0
ExplanationOfBenefit.processNote.language
  • Change binding strength from extensible to preferred
ExplanationOfBenefit.benefitPeriod
  • Added Element
ExplanationOfBenefit.organization
  • deleted
ExplanationOfBenefit.payee.resourceType
  • deleted
ExplanationOfBenefit.employmentImpacted
  • deleted
ExplanationOfBenefit.hospitalization
  • deleted
ExplanationOfBenefit.item.detail.type
  • deleted
ExplanationOfBenefit.item.detail.subDetail.type
  • deleted
ExplanationOfBenefit.addItem.revenue
  • deleted
ExplanationOfBenefit.addItem.category
  • deleted
ExplanationOfBenefit.addItem.detail.revenue
  • deleted
ExplanationOfBenefit.addItem.detail.category
  • deleted
ExplanationOfBenefit.totalCost
  • deleted
ExplanationOfBenefit.unallocDeductable
  • deleted
ExplanationOfBenefit.totalBenefit
  • deleted
ExplanationOfBenefit.benefitBalance.subCategory
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors).)

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
ProcessPriority (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
FundsReserve (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
FundsReserve (Example)
... related 0..*BackboneElementPrior or corollary claims
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
PayeeType (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
V3 Value SetActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite