Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | TU | DomainResource | Explanation of Benefit resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension |
|||||
identifier | 0..* | Identifier | Business Identifier for the resource
|
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traceNumber | 0..* | Identifier | Number for tracking
|
|||||
status | ?! Σ | 1..1 | code | active | cancelled | draft | entered-in-error
Binding: Explanation Of Benefit Status ( Required) |
||||
type | Σ | 1..1 | CodeableConcept | Category or discipline
Binding: Claim Type Codes ( Extensible) |
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subType | 0..1 | CodeableConcept | More granular claim type
Binding: Example Claim SubType Codes ( Example) |
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use | Σ | 1..1 | code | claim | preauthorization | predetermination
Binding: Use ( Required) |
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patient | Σ | 1..1 | Reference( Patient) | The recipient of the products and services
|
||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
|
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created | Σ | 1..1 | dateTime | Response creation date
|
||||
enterer | 0..1 | Reference( Practitioner | PractitionerRole | Patient | RelatedPerson) | Author of the claim
|
|||||
insurer | Σ | 0..1 | Reference( Organization) | Party responsible for reimbursement
|
||||
provider | Σ | 0..1 | Reference( Practitioner | PractitionerRole | Organization) | Party responsible for the claim
|
||||
priority | 0..1 | CodeableConcept | Desired processing urgency
Binding: Process Priority Codes ( Example) |
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fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds
Binding: Funds Reservation Codes ( Example) |
|||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status
Binding: Funds Reservation Codes ( Example) |
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related | 0..* | BackboneElement | Prior or corollary claims
|
|||||
claim | 0..1 | Reference( Claim) | Reference to the related claim
|
|||||
relationship | 0..1 | CodeableConcept | How the reference claim is related
Binding: Example Related Claim Relationship Codes ( Example) |
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reference | 0..1 | Identifier | File or case reference
|
|||||
prescription | 0..1 | Reference( MedicationRequest | VisionPrescription) | Prescription authorizing services or products
|
|||||
originalPrescription | 0..1 | Reference( MedicationRequest) | Original prescription if superceded by fulfiller
|
|||||
event | 0..* | BackboneElement | Event information
|
|||||
type | 1..1 | CodeableConcept | Specific event
Binding: Dates Type Codes ( Example) |
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when[x] | 1..1 | Occurance date or period
|
||||||
whenDateTime | dateTime | |||||||
whenPeriod | Period | |||||||
payee | 0..1 | BackboneElement | Recipient of benefits payable
|
|||||
type | 0..1 | CodeableConcept | Category of recipient
Binding: Claim Payee Type Codes ( Example) |
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party | 0..1 | Reference( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
|
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referral | 0..1 | Reference( ServiceRequest) | Treatment Referral
|
|||||
encounter | 0..* | Reference( Encounter) | Encounters associated with the listed treatments
|
|||||
facility | 0..1 | Reference( Location | Organization) | Servicing Facility
|
|||||
claim | 0..1 | Reference( Claim) | Claim reference
|
|||||
claimResponse | 0..1 | Reference( ClaimResponse) | Claim response reference
|
|||||
outcome | Σ | 1..1 | code | queued | complete | error | partial
Binding: Claim Processing Codes ( Required) |
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decision | Σ | 0..1 | CodeableConcept | Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Example) |
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disposition | 0..1 | string | Disposition Message
|
|||||
preAuthRef | 0..* | string | Preauthorization reference
|
|||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period
|
|||||
diagnosisRelatedGroup | 0..1 | CodeableConcept | Package billing code
Binding: Example Diagnosis Related Group Codes ( Example) |
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careTeam | 0..* | BackboneElement | Care Team members
|
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sequence | 1..1 | positiveInt | Order of care team
|
|||||
provider | 1..1 | Reference( Practitioner | PractitionerRole | Organization) | Practitioner or organization
|
|||||
responsible | 0..1 | boolean | Indicator of the lead practitioner
|
|||||
role | 0..1 | CodeableConcept | Function within the team
Binding: Claim Care Team Role Codes ( Example) |
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specialty | 0..1 | CodeableConcept | Practitioner or provider specialization
Binding: Example Provider Qualification Codes ( Example) |
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supportingInfo | 0..* | BackboneElement | Supporting information
|
|||||
sequence | 1..1 | positiveInt | Information instance identifier
|
|||||
category | 1..1 | CodeableConcept | Classification of the supplied information
Binding: Claim Information Category Codes ( Example) |
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code | 0..1 | CodeableConcept | Type of information
Binding: Exception Codes ( Example) |
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timing[x] | 0..1 | When it occurred
|
||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided
|
||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference( Any) | |||||||
valueIdentifier | Identifier | |||||||
reason | 0..1 | Coding | Explanation for the information
Binding: Missing Tooth Reason Codes ( Example) |
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diagnosis | 0..* | BackboneElement | Pertinent diagnosis information
|
|||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier
|
|||||
diagnosis[x] | 1..1 | Nature of illness or problem
Binding: ICD-10 Codes ( Example) |
||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference( Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes ( Example) |
|||||
onAdmission | 0..1 | CodeableConcept | Present on admission
Binding: Example Diagnosis on Admission Codes ( Example) |
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procedure | 0..* | BackboneElement | Clinical procedures performed
|
|||||
sequence | 1..1 | positiveInt | Procedure instance identifier
|
|||||
type | 0..* | CodeableConcept | Category of Procedure
Binding: Example Procedure Type Codes ( Example) |
|||||
date | 0..1 | dateTime | When the procedure was performed
|
|||||
procedure[x] | 1..1 | Specific clinical procedure
Binding: ICD-10 Procedure Codes ( Example) |
||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference( Procedure) | |||||||
udi | 0..* | Reference( Device) | Unique device identifier
|
|||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
|
|||||
insurance | Σ | 0..* | BackboneElement | Patient insurance information
|
||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
|
||||
coverage | Σ | 1..1 | Reference( Coverage) | Insurance information
|
||||
preAuthRef | 0..* | string | Prior authorization reference number
|
|||||
accident | 0..1 | BackboneElement | Details of the event
|
|||||
date | 0..1 | date | When the incident occurred
|
|||||
type | 0..1 | CodeableConcept | The nature of the accident
Binding: ActIncidentCode ( Extensible) |
|||||
location[x] | 0..1 | Where the event occurred
|
||||||
locationAddress | Address | |||||||
locationReference | Reference( Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
item | 0..* | BackboneElement | Product or service provided
|
|||||
sequence | 1..1 | positiveInt | Item instance identifier
|
|||||
careTeamSequence | 0..* | positiveInt | Applicable care team members
|
|||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses
|
|||||
procedureSequence | 0..* | positiveInt | Applicable procedures
|
|||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
category | 0..1 | CodeableConcept | Benefit classification
Binding: Benefit Category Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
request | 0..* | Reference( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service
|
|||||
modifier | 0..* | CodeableConcept | Product or service billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under
Binding: Example Program Reason Codes ( Example) |
|||||
serviced[x] | 0..1 | Date or dates of service or product delivery
|
||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied
Binding: Example Service Place Codes ( Example) |
||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference( Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
udi | 0..* | Reference( Device) | Unique device identifier
|
|||||
bodySite | 0..* | BackboneElement | Anatomical location
|
|||||
site | 1..* | CodeableReference( BodyStructure) | Location
Binding: Oral Site Codes ( Example) |
|||||
subSite | 0..* | CodeableConcept | Sub-location
Binding: Surface Codes ( Example) |
|||||
encounter | 0..* | Reference( Encounter) | Encounters associated with the listed treatments
|
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | BackboneElement | Adjudication results
|
|||||
decision | 0..1 | CodeableConcept | Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Example) |
|||||
reason | 0..* | CodeableConcept | Reason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes ( Example) |
|||||
preAuthRef | 0..1 | string | Preauthorization reference
|
|||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period
|
|||||
adjudication | 0..* | BackboneElement | Adjudication details
|
|||||
category | 1..1 | CodeableConcept | Type of adjudication information
Binding: Adjudication Value Codes ( Example) |
|||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome
Binding: Adjudication Reason Codes ( Example) |
|||||
amount | 0..1 | Money | Monetary amount
|
|||||
quantity | 0..1 | Quantity | Non-monitary value
|
|||||
detail | 0..* | BackboneElement | Additional items
|
|||||
sequence | 1..1 | positiveInt | Product or service provided
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
category | 0..1 | CodeableConcept | Benefit classification
Binding: Benefit Category Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under
Binding: Example Program Reason Codes ( Example) |
|||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
udi | 0..* | Reference( Device) | Unique device identifier
|
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | see reviewOutcome | Detail level adjudication results
|
|||||
adjudication | 0..* | see adjudication | Detail level adjudication details
|
|||||
subDetail | 0..* | BackboneElement | Additional items
|
|||||
sequence | 1..1 | positiveInt | Product or service provided
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
category | 0..1 | CodeableConcept | Benefit classification
Binding: Benefit Category Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under
Binding: Example Program Reason Codes ( Example) |
|||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
udi | 0..* | Reference( Device) | Unique device identifier
|
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | see reviewOutcome | Subdetail level adjudication results
|
|||||
adjudication | 0..* | see adjudication | Subdetail level adjudication details
|
|||||
addItem | 0..* | BackboneElement | Insurer added line items
|
|||||
itemSequence | 0..* | positiveInt | Item sequence number
|
|||||
detailSequence | 0..* | positiveInt | Detail sequence number
|
|||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
provider | 0..* | Reference( Practitioner | PractitionerRole | Organization) | Authorized providers
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
request | 0..* | Reference( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service
|
|||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under
Binding: Example Program Reason Codes ( Example) |
|||||
serviced[x] | 0..1 | Date or dates of service or product delivery
|
||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied
Binding: Example Service Place Codes ( Example) |
||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference( Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
bodySite | 0..* | BackboneElement | Anatomical location
|
|||||
site | 1..* | CodeableReference( BodyStructure) | Location
Binding: Oral Site Codes ( Example) |
|||||
subSite | 0..* | CodeableConcept | Sub-location
Binding: Surface Codes ( Example) |
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | see reviewOutcome | Additem level adjudication results
|
|||||
adjudication | 0..* | see adjudication | Added items adjudication
|
|||||
detail | 0..* | BackboneElement | Insurer added line items
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | see reviewOutcome | Additem detail level adjudication results
|
|||||
adjudication | 0..* | see adjudication | Added items adjudication
|
|||||
subDetail | 0..* | BackboneElement | Insurer added line items
|
|||||
traceNumber | 0..* | Identifier | Number for tracking
|
|||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code
Binding: Example Revenue Center Codes ( Example) |
|||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code
Binding: USCLS Codes ( Example) |
|||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes
Binding: USCLS Codes ( Example) |
|||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers
Binding: Modifier type Codes ( Example) |
|||||
patientPaid | 0..1 | Money | Paid by the patient
|
|||||
quantity | 0..1 | SimpleQuantity | Count of products or services
|
|||||
unitPrice | 0..1 | Money | Fee, charge or cost per item
|
|||||
factor | 0..1 | decimal | Price scaling factor
|
|||||
tax | 0..1 | Money | Total tax
|
|||||
net | 0..1 | Money | Total item cost
|
|||||
noteNumber | 0..* | positiveInt | Applicable note numbers
|
|||||
reviewOutcome | 0..1 | see reviewOutcome | Additem subdetail level adjudication results
|
|||||
adjudication | 0..* | see adjudication | Added items adjudication
|
|||||
adjudication | 0..* | see adjudication | Header-level adjudication
|
|||||
total | Σ | 0..* | BackboneElement | Adjudication totals
|
||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information
Binding: Adjudication Value Codes ( Example) |
||||
amount | Σ | 1..1 | Money | Financial total for the category
|
||||
payment | 0..1 | BackboneElement | Payment Details
|
|||||
type | 0..1 | CodeableConcept | Partial or complete payment
Binding: Example Payment Type Codes ( Example) |
|||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues
|
|||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance
Binding: Payment Adjustment Reason Codes ( Example) |
|||||
date | 0..1 | date | Expected date of payment
|
|||||
amount | 0..1 | Money | Payable amount after adjustment
|
|||||
identifier | 0..1 | Identifier | Business identifier for the payment
|
|||||
formCode | 0..1 | CodeableConcept | Printed form identifier
Binding: Form Codes ( Example) |
|||||
form | 0..1 | Attachment | Printed reference or actual form
|
|||||
processNote | 0..* | BackboneElement | Note concerning adjudication
|
|||||
number | 0..1 | positiveInt | Note instance identifier
|
|||||
type | 0..1 | CodeableConcept | Note purpose
Binding: NoteType ( Extensible) |
|||||
text | 0..1 | string | Note explanatory text
|
|||||
language | 0..1 | CodeableConcept | Language of the text
Binding: All Languages ( Required)
|
|||||
benefitPeriod | 0..1 | Period | When the benefits are applicable
|
|||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category
|
|||||
category | 1..1 | CodeableConcept | Benefit classification
Binding: Benefit Category Codes ( Example) |
|||||
excluded | 0..1 | boolean | Excluded from the plan
|
|||||
name | 0..1 | string | Short name for the benefit
|
|||||
description | 0..1 | string | Description of the benefit or services covered
|
|||||
network | 0..1 | CodeableConcept | In or out of network
Binding: Network Type Codes ( Example) |
|||||
unit | 0..1 | CodeableConcept | Individual or family
Binding: Unit Type Codes ( Example) |
|||||
term | 0..1 | CodeableConcept | Annual or lifetime
Binding: Benefit Term Codes ( Example) |
|||||
financial | 0..* | BackboneElement | Benefit Summary
|
|||||
type | 1..1 | CodeableConcept | Benefit classification
Binding: Benefit Type Codes ( Example) |
|||||
allowed[x] | 0..1 | Benefits allowed
|
||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used
|
||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |