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13.10 Resource ExplanationOfBenefit - Content

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

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

13.10.1 Scope and Usage

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

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

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

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

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

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

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

13.10.1.1 Additional Information

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

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining EOBs: EOBs may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy: 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax: Tax handling of Goods, products, and Services.

13.10.2 Boundaries and Relationships

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

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

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

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

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

13.10.3 References to this Resource

13.10.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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

... 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)
... subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... 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)
... 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)
... 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)
.... 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)
.... 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)
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... 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)
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... 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)
... careTeam 0..* BackboneElement Care Team members

.... 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)
.... specialty 0..1 CodeableConcept Practitioner or provider specialization
Binding: Example Provider Qualification Codes (Example)
... 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)
.... code 0..1 CodeableConcept Type of information
Binding: Exception Codes (Example)
.... 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)
... 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)
... 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 icon (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)
Additional BindingsPurpose
Common Languages Starter Set

... 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

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.10.4.1 Terminology Bindings

Path ValueSet Type Documentation
ExplanationOfBenefit.status ExplanationOfBenefitStatus Required

A code specifying the state of the resource instance.
ExplanationOfBenefit.type ClaimTypeCodes Extensible

This value set includes Claim Type codes.
ExplanationOfBenefit.subType ExampleClaimSubTypeCodes Example

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.
ExplanationOfBenefit.use Use Required

The purpose of the Claim: predetermination, preauthorization, claim.
ExplanationOfBenefit.priority ProcessPriorityCodes Example

This value set includes the financial processing priority codes.
ExplanationOfBenefit.fundsReserveRequested FundsReservationCodes Example

This value set includes sample funds reservation type codes.
ExplanationOfBenefit.fundsReserve FundsReservationCodes Example

This value set includes sample funds reservation type codes.
ExplanationOfBenefit.related.relationship ExampleRelatedClaimRelationshipCodes Example

This value set includes sample Related Claim Relationship codes.
ExplanationOfBenefit.event.type DatesTypeCodes (a valid code from Dates Event Type Codes) Example

This value set includes sample Dates Type codes.
ExplanationOfBenefit.payee.type ClaimPayeeTypeCodes (a valid code from Payee Type Codes icon) Example

This value set includes sample Payee Type codes.
ExplanationOfBenefit.outcome ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes) Required

This value set includes Claim Processing Outcome codes.
ExplanationOfBenefit.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) Example

This value set includes Claim Adjudication Decision codes.
ExplanationOfBenefit.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.
ExplanationOfBenefit.careTeam.role ClaimCareTeamRoleCodes Example

This value set includes sample Claim Care Team Role codes.
ExplanationOfBenefit.careTeam.specialty ExampleProviderQualificationCodes Example

This value set includes sample Provider Qualification codes.
ExplanationOfBenefit.supportingInfo.category ClaimInformationCategoryCodes Example

This value set includes sample Information Category codes.
ExplanationOfBenefit.supportingInfo.code ExceptionCodes Example

This value set includes sample Exception codes.
ExplanationOfBenefit.supportingInfo.reason MissingToothReasonCodes Example

This value set includes sample Missing Tooth Reason codes.
ExplanationOfBenefit.diagnosis.diagnosis[x] ICD10Codes (a valid code from ICD-10 icon) Example

This value set includes sample ICD-10 codes.
ExplanationOfBenefit.diagnosis.type ExampleDiagnosisTypeCodes Example

This value set includes example Diagnosis Type codes.
ExplanationOfBenefit.diagnosis.onAdmission ExampleDiagnosisOnAdmissionCodes Example

This value set includes example Diagnosis on Admission codes.
ExplanationOfBenefit.procedure.type ExampleProcedureTypeCodes Example

This value set includes example Procedure Type codes.
ExplanationOfBenefit.procedure.procedure[x] ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes) Example

This value set includes sample ICD-10 Procedure codes.
ExplanationOfBenefit.accident.type ActIncidentCode icon Extensible

Set of codes indicating the type of incident or accident.
ExplanationOfBenefit.item.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.item.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
ExplanationOfBenefit.item.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.item.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ExplanationOfBenefit.item.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
ExplanationOfBenefit.item.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
ExplanationOfBenefit.item.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
ExplanationOfBenefit.item.reviewOutcome.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) Example

This value set includes Claim Adjudication Decision codes.
ExplanationOfBenefit.item.reviewOutcome.reason ClaimAdjudicationDecisionReasonCodes Example

This value set includes example Claim Adjudication Decision Reason codes.
ExplanationOfBenefit.item.adjudication.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.
ExplanationOfBenefit.item.adjudication.reason AdjudicationReasonCodes Example

This value set includes smattering of Adjudication Reason codes.
ExplanationOfBenefit.item.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.item.detail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
ExplanationOfBenefit.item.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.item.detail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ExplanationOfBenefit.item.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.item.detail.subDetail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
ExplanationOfBenefit.item.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.item.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.item.detail.subDetail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ExplanationOfBenefit.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.addItem.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.addItem.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ExplanationOfBenefit.addItem.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
ExplanationOfBenefit.addItem.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
ExplanationOfBenefit.addItem.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
ExplanationOfBenefit.addItem.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.addItem.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ExplanationOfBenefit.addItem.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ExplanationOfBenefit.addItem.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ExplanationOfBenefit.total.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.
ExplanationOfBenefit.payment.type ExamplePaymentTypeCodes Example

This value set includes example Payment Type codes.
ExplanationOfBenefit.payment.adjustmentReason PaymentAdjustmentReasonCodes Example

This value set includes smattering of Payment Adjustment Reason codes.
ExplanationOfBenefit.formCode FormCodes Example

This value set includes a sample set of Forms codes.
ExplanationOfBenefit.processNote.type NoteType Extensible

The presentation types of notes.
ExplanationOfBenefit.processNote.language AllLanguages (a valid code from Tags for the Identification of Languages icon) Required

This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47)
  Common Languages starter
ExplanationOfBenefit.benefitBalance.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
ExplanationOfBenefit.benefitBalance.network NetworkTypeCodes Example

This value set includes a smattering of Network type codes.
ExplanationOfBenefit.benefitBalance.unit UnitTypeCodes Example

This value set includes a smattering of Unit type codes.
ExplanationOfBenefit.benefitBalance.term BenefitTermCodes Example

This value set includes a smattering of Benefit Term codes.
ExplanationOfBenefit.benefitBalance.financial.type BenefitTypeCodes Example

This value set includes a smattering of Benefit type codes.



13.10.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an .elementSequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

The .noteNumber element, which appears at the .item, .detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumbers for each of the appropriate line items or details.

13.10.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
care-team reference Member of the CareTeam ExplanationOfBenefit.careTeam.provider
(Practitioner, Organization, PractitionerRole)
claim reference The reference to the claim ExplanationOfBenefit.claim
(Claim)
coverage reference The plan under which the claim was adjudicated ExplanationOfBenefit.insurance.coverage
(Coverage)
created date The creation date for the EOB ExplanationOfBenefit.created
detail-udi reference UDI associated with a line item detail product or service ExplanationOfBenefit.item.detail.udi
(Device)
disposition string The contents of the disposition message ExplanationOfBenefit.disposition
encounter reference Encounters associated with a billed line item ExplanationOfBenefit.item.encounter
(Encounter)		 29 Resources
enterer reference The party responsible for the entry of the Claim ExplanationOfBenefit.enterer
(Practitioner, Patient, PractitionerRole, RelatedPerson)
facility reference Facility responsible for the goods and services ExplanationOfBenefit.facility
(Organization, Location)
identifier token The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier 65 Resources
item-udi reference UDI associated with a line item product or service ExplanationOfBenefit.item.udi
(Device)
patient reference The reference to the patient ExplanationOfBenefit.patient
(Patient)		 65 Resources
payee reference The party receiving any payment for the Claim ExplanationOfBenefit.payee.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
procedure-udi reference UDI associated with a procedure ExplanationOfBenefit.procedure.udi
(Device)
provider reference The reference to the provider ExplanationOfBenefit.provider
(Practitioner, Organization, PractitionerRole)
status token Status of the instance ExplanationOfBenefit.status
subdetail-udi reference UDI associated with a line item detail subdetail product or service ExplanationOfBenefit.item.detail.subDetail.udi
(Device)