ExplanationOfBenefit - FHIR v3.4.0
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13.10 Resource ExplanationOfBenefit - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: 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 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.

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 used and/or remaining.

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
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type 0..1CodeableConceptType or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use Σ0..1codeclaim | preauthorization | predetermination
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... insurer 0..1Reference(Organization)Insurer responsible for the EOB
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider for the claim
... 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 0..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... 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..1IdentifierRelated file 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..1BackboneElementParty to be paid any benefits payable
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Claim Payee Type Codes (Example)
.... resource 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Extensible)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Party to receive the payable
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of 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..1Additional Data or supporting information
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingReason associated with the information
Missing Tooth Reason Codes (Example)
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntNumber to convey order of careteam
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... diagnosis 0..*BackboneElementList of Diagnosis
.... sequence 1..1positiveIntNumber to convey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
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..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..*BackboneElementInsurance or medical plan
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
... accident 0..1BackboneElementDetails of an accident
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Extensible)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamSequence 0..*positiveIntApplicable careteam 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..1CodeableConceptType of service or product
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
..... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
...... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationLanguage if different from the resource
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntService instances
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... billcode 0..1CodeableConceptBilling 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 point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... billcode 0..1CodeableConceptBilling 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 point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationAdded items adjudication
... total 0..*BackboneElementAdjudication totals
.... category 1..1CodeableConceptAdjudication category such as submitted, co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
.... amount 1..1MoneyMonetary amount
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... processNote 0..*BackboneElementProcessing notes
.... number 0..1positiveIntSequence number for this note
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage if different from the resource
Common Languages (Preferred but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptType of services covered
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..1CodeableConceptDeductable, visits, benefit amount
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)The EOB Business Identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..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 [0..1] « The type or discipline-style of the claim. (Strength=Extensible)Claim Type + »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill TypesubType : CodeableConcept [0..1] « A more granulat claim typecode. (Strength=Example)Example Claim SubType ?? »A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is soughtuse : code [0..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when this resource was createdcreated : dateTime [0..1]The person who created the explanation of benefitenterer : Reference [0..1] « Practitioner|PractitionerRole »The insurer which is responsible for the explanation of benefitinsurer : Reference [0..1] « Organization »The provider which is responsible for the claimprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaim : Reference [0..1] « Claim »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaimResponse : Reference [0..1] « ClaimResponse »Processing outcome errror, partial or complete processingoutcome : code [0..1] « The result of the claim processing. (Strength=Required)Claim Processing ! »A description of the status of the adjudicationdisposition : string [0..1]Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example, prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - e.g. Property/Casualy insurer claim # or Workers Compensation case # reference : 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 ?? »organization | patient | practitioner | relatedpersonresource : Coding [0..1] « The type of payee Resource. (Strength=Extensible)PayeeResourceType+ »Party to be reimbursed: Subscriber, provider, otherparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »SupportingInformationSequence of the information element which serves to provide a linksequence : 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)Claim Information Category ?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »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) »For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the contentreason : Coding [0..1] « Reason codes for the missing teeth. (Strength=Example)Missing Tooth Reason ?? »CareTeamSequence of careteam which serves to order and provide a linksequence : positiveInt [1..1]The members of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The practitioner who is billing and responsible for the claimed services rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example)Example Provider Qualificatio...?? »DiagnosisSequence of diagnosis which serves to provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10 ?? »The type of the Diagnosis, for example: admitting, primary, secondary, dischargetype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)Example Diagnosis Type ?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example)Example Diagnosis on Admissio...?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example)Example Diagnosis Related Gro...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes. (Strength=Example) ICD-10 Procedure ?? »InsuranceThe instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim was adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »AccidentDate of an accident which these services are addressingdate : date [0..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)ActIncidentCode+ »Where the accident occurredlocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]Careteam applicable for this service or product linecareTeamSequence : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisSequence : positiveInt [0..*]Procedures applicable for this service or product lineprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information pplicable for this service or product lineinformationSequence : 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)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)Benefit Category ?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)Example Program Reason ?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place where the service is rendered. (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of 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)Oral Site ?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)Surface ?? »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)Adjudication Value ?? »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « Adjudication reason codes. (Strength=Example)Adjudication Reason ?? »Monitory amount associated with the codeamount : Money [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA service line numbersequence : 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)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)Benefit Category ?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersequence : 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)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)Benefit Category ?? »A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemList of input service items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubDetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)Example Program Reason ?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place where the service is rendered. (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : 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)Oral Site ?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)Surface ?? »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemDetailIf this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemDetailSubDetailIf this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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)Modifier type ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]TotalCode indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)Adjudication Value ?? »Monitory amount associated with the codeamount : Money [1..1]PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment. (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example)Payment Adjustment Reason ?? »Estimated payment datedate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identifieridentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Preferred)Common Languages? »BenefitBalanceDental, Vision, Medical, Pharmacy, Rehab etccategory : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. (Strength=Example)Benefit Category ?? »True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedallowed[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedused[x] : Type [0..1] « unsignedInt|Money »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..*]An accident which resulted in the need for healthcare servicesaccident[0..1]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]Third-tier of goods and servicessubDetail[0..*]Second-tier of goods and servicesdetail[0..*]First-tier of goods and servicesitem[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 servicesaddItem[0..*]Totals for amounts submitted, co-pays, benefits payable etctotal[0..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textprocessNote[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 --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Insurer responsible for the EOB --></insurer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider for the claim --></provider>
 <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]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claim -->
  <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 Related 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 Party to be paid any benefits payable -->
  <type><!-- 0..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resource><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resource>
  <party><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party>
 </payee>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept General class of 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) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 Coding Reason associated with the information --></reason>
 </information>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of careteam -->
  <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|Organization) Member of the Care Team --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing practitioner -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <diagnosis>  <!-- 0..* List of Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></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..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
 </insurance>
 <accident>  <!-- 0..1 Details of an accident -->
  <date value="[date]"/><!-- 0..1 When the accident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careteam 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 Type of service or product --></category>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></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 Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Language if different from the resource --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <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 point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <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 point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category>
  <amount><!-- 1..1 Money Monetary amount --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of Payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Type of services covered --></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 Deductable, visits, benefit amount --></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
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "insurer" : { Reference(Organization) }, // Insurer responsible for the EOB
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider for the claim
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "related" : [{ // Related Claims which may be revelant to processing this claim
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other
    "resource" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Party to receive the payable
  },
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { Coding } // Reason associated with the information
  }],
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Number to convey order of careteam
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Member of the Care Team
    "responsible" : <boolean>, // Billing practitioner
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "diagnosis" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to convey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. 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" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : [{ // Insurance or medical plan
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) } // R!  Insurance information
  }],
  "accident" : { // Details of an accident
    "date" : "<date>", // When the accident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamSequence" : ["<positiveInt>"], // Applicable careteam 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 }, // Type of service or product
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. 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 point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "billcode" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Language if different from the resource
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. 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 point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "subDetail" : [{ // Insurer added line items
        "billcode" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    "amount" : { Money } // R!  Monetary amount
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanitory text
    "language" : { CodeableConcept } // Language if different from the resource
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Type of services covered
    "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!  Deductable, visits, benefit amount
      // 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
  fhir:ExplanationOfBenefit.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information
  fhir:ExplanationOfBenefit.use [ code ]; # 0..1 claim | preauthorization | predetermination
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Insurer responsible for the EOB
  fhir:ExplanationOfBenefit.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider for the claim
  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 ]; # 0..1 queued | complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claim
    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 Related 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 Party to be paid any benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resource [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:ExplanationOfBenefit.payee.party [ Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:ExplanationOfBenefit.information.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 General class of information
    fhir:ExplanationOfBenefit.information.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.information.timingDate [ date ]
      fhir:ExplanationOfBenefit.information.timingPeriod [ Period ]
    # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data or supporting information. One of these 5
      fhir:ExplanationOfBenefit.information.valueBoolean [ boolean ]
      fhir:ExplanationOfBenefit.information.valueString [ string ]
      fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.information.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.information.valueReference [ Reference(Any) ]
    fhir:ExplanationOfBenefit.information.reason [ Coding ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Number to convey order of careteam
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 1..1 Member of the Care Team
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:ExplanationOfBenefit.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* List of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to convey order of diagnosis
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. 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..* Procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 0..* Insurance or medical plan
    fhir:ExplanationOfBenefit.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
  ], ...;
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of an accident
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:ExplanationOfBenefit.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careteam 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 Type of service or product
    fhir:ExplanationOfBenefit.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. 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 point
    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 Service Location
    fhir:ExplanationOfBenefit.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      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-monitory value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.item.detail.billcode [ CodeableConcept ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      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 point
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      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 Service instance
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:ExplanationOfBenefit.item.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Billing Code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        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 point
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Language if different from the resource
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances
    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.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.addItem.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.addItem.servicedDate [ date ]
      fhir:ExplanationOfBenefit.addItem.servicedPeriod [ Period ]
    # ExplanationOfBenefit.addItem.location[x] : 0..1 Place of service. 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 point
    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 Service Location
    fhir:ExplanationOfBenefit.addItem.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    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.billcode [ CodeableConcept ]; # 0..1 Billing 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 point
      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..* List of note numbers which apply
      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.billcode [ CodeableConcept ]; # 0..1 Billing 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 point
        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..* List of note numbers which apply
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.total [ # 0..* Adjudication totals
    fhir:ExplanationOfBenefit.total.category [ CodeableConcept ]; # 1..1 Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    fhir:ExplanationOfBenefit.total.amount [ Money ]; # 1..1 Monetary amount
  ], ...;
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment Details
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    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 Identifier of the payment instrument
  ];
  fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.processNote [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Sequence number for this note
    fhir:ExplanationOfBenefit.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
    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 Deductable, visits, benefit amount
      # 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.type
  • Change binding strength from required to extensible
ExplanationOfBenefit.subType
  • Max Cardinality changed from * to 1
ExplanationOfBenefit.use
  • Added Element
ExplanationOfBenefit.enterer
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole)
ExplanationOfBenefit.provider
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)
ExplanationOfBenefit.referral
  • Type changed from Reference(ReferralRequest) to Reference(ServiceRequest)
ExplanationOfBenefit.outcome
  • Type changed from CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.payee.resource
  • Added Element
ExplanationOfBenefit.payee.party
  • Type changed from Reference(Practitioner|Organization|Patient|RelatedPerson) to Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson)
ExplanationOfBenefit.information.value[x]
  • Remove Reference(Resource), Add boolean, Add Reference(Resource)
ExplanationOfBenefit.careTeam.provider
  • Type changed from Reference(Practitioner|Organization) to Reference(Practitioner|PractitionerRole|Organization)
ExplanationOfBenefit.diagnosis.diagnosis[x]
  • Remove Reference(Condition), Add Reference(Condition)
ExplanationOfBenefit.diagnosis.onAdmission
  • Added Element
ExplanationOfBenefit.procedure.procedure[x]
  • Remove Reference(Procedure), Add Reference(Procedure)
ExplanationOfBenefit.insurance
  • Max Cardinality changed from 1 to *
ExplanationOfBenefit.insurance.focal
  • Added Element
ExplanationOfBenefit.insurance.coverage
  • Min Cardinality changed from 0 to 1
ExplanationOfBenefit.accident.type
  • Change binding strength from required to extensible
ExplanationOfBenefit.accident.location[x]
  • Remove Reference(Location), Add Reference(Location)
ExplanationOfBenefit.item.careTeamSequence
  • Added Element
ExplanationOfBenefit.item.diagnosisSequence
  • Added Element
ExplanationOfBenefit.item.procedureSequence
  • Added Element
ExplanationOfBenefit.item.informationSequence
  • Added Element
ExplanationOfBenefit.item.billcode
  • Added Element
ExplanationOfBenefit.item.location[x]
  • Remove Reference(Location), Add Reference(Location)
ExplanationOfBenefit.item.detail.billcode
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.billcode
  • Added Element
ExplanationOfBenefit.addItem.itemSequence
  • Added Element
ExplanationOfBenefit.addItem.detailSequence
  • Added Element
ExplanationOfBenefit.addItem.subDetailSequence
  • Added Element
ExplanationOfBenefit.addItem.provider
  • Added Element
ExplanationOfBenefit.addItem.billcode
  • Added Element
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
  • Added Element
ExplanationOfBenefit.addItem.bodySite
  • Added Element
ExplanationOfBenefit.addItem.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.billcode
  • Added Element
ExplanationOfBenefit.addItem.detail.quantity
  • Added Element
ExplanationOfBenefit.addItem.detail.unitPrice
  • Added Element
ExplanationOfBenefit.addItem.detail.factor
  • Added Element
ExplanationOfBenefit.addItem.detail.net
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.billcode
  • Added 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.total
  • Added Element
ExplanationOfBenefit.total.category
  • Added Element
ExplanationOfBenefit.total.amount
  • Added Element
ExplanationOfBenefit.processNote.type
  • Type changed from CodeableConcept to code
ExplanationOfBenefit.processNote.language
  • Remove Binding http://hl7.org/fhir/ValueSet/languages (extensible)
ExplanationOfBenefit.organization
  • deleted
ExplanationOfBenefit.payee.resourceType
  • deleted
ExplanationOfBenefit.insurance.preAuthRef
  • deleted
ExplanationOfBenefit.employmentImpacted
  • deleted
ExplanationOfBenefit.hospitalization
  • deleted
ExplanationOfBenefit.item.careTeamLinkId
  • deleted
ExplanationOfBenefit.item.diagnosisLinkId
  • deleted
ExplanationOfBenefit.item.procedureLinkId
  • deleted
ExplanationOfBenefit.item.informationLinkId
  • deleted
ExplanationOfBenefit.item.service
  • deleted
ExplanationOfBenefit.item.detail.type
  • deleted
ExplanationOfBenefit.item.detail.service
  • deleted
ExplanationOfBenefit.item.detail.subDetail.type
  • deleted
ExplanationOfBenefit.item.detail.subDetail.service
  • deleted
ExplanationOfBenefit.addItem.sequenceLinkId
  • deleted
ExplanationOfBenefit.addItem.revenue
  • deleted
ExplanationOfBenefit.addItem.category
  • deleted
ExplanationOfBenefit.addItem.service
  • deleted
ExplanationOfBenefit.addItem.fee
  • deleted
ExplanationOfBenefit.addItem.detail.revenue
  • deleted
ExplanationOfBenefit.addItem.detail.category
  • deleted
ExplanationOfBenefit.addItem.detail.service
  • deleted
ExplanationOfBenefit.addItem.detail.fee
  • 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 of which 1 fail to execute.)

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
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type 0..1CodeableConceptType or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use Σ0..1codeclaim | preauthorization | predetermination
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... insurer 0..1Reference(Organization)Insurer responsible for the EOB
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider for the claim
... 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 0..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... 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..1IdentifierRelated file 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..1BackboneElementParty to be paid any benefits payable
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Claim Payee Type Codes (Example)
.... resource 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Extensible)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Party to receive the payable
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of 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..1Additional Data or supporting information
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingReason associated with the information
Missing Tooth Reason Codes (Example)
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntNumber to convey order of careteam
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... diagnosis 0..*BackboneElementList of Diagnosis
.... sequence 1..1positiveIntNumber to convey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
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..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..*BackboneElementInsurance or medical plan
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
... accident 0..1BackboneElementDetails of an accident
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Extensible)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamSequence 0..*positiveIntApplicable careteam 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..1CodeableConceptType of service or product
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
..... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
...... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...