This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Financial Management Work Group | Maturity Level: 2 | Trial Use | Security Category: Patient | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Detailed Descriptions for the elements in the ExplanationOfBenefit resource.
ExplanationOfBenefit | |||||
Element Id | ExplanationOfBenefit | ||||
Definition | 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. | ||||
Short Display | Explanation of Benefit resource | ||||
Cardinality | 0..* | ||||
Type | DomainResource | ||||
Alternate Names | EOB | ||||
Summary | false | ||||
ExplanationOfBenefit.identifier | |||||
Element Id | ExplanationOfBenefit.identifier | ||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short Display | Business Identifier for the resource | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Summary | false | ||||
ExplanationOfBenefit.traceNumber | |||||
Element Id | ExplanationOfBenefit.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.status | |||||
Element Id | ExplanationOfBenefit.status | ||||
Definition | The status of the resource instance. | ||||
Short Display | active | cancelled | draft | entered-in-error | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Explanation Of Benefit Status (Required) | ||||
Type | code | ||||
Is Modifier | true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) | ||||
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. | ||||
Summary | true | ||||
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||
ExplanationOfBenefit.type | |||||
Element Id | ExplanationOfBenefit.type | ||||
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | ||||
Short Display | Category or discipline | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Claim Type Codes (Extensible) | ||||
Type | CodeableConcept | ||||
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication. | ||||
Summary | true | ||||
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements. | ||||
ExplanationOfBenefit.subType | |||||
Element Id | ExplanationOfBenefit.subType | ||||
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | ||||
Short Display | More granular claim type | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Claim SubType Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. | ||||
Summary | false | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
ExplanationOfBenefit.use | |||||
Element Id | ExplanationOfBenefit.use | ||||
Definition | A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided. | ||||
Short Display | claim | preauthorization | predetermination | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Use (Required) | ||||
Type | code | ||||
Requirements | This element is required to understand the nature of the request for adjudication. | ||||
Summary | true | ||||
ExplanationOfBenefit.patient | |||||
Element Id | ExplanationOfBenefit.patient | ||||
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. | ||||
Short Display | The recipient of the products and services | ||||
Cardinality | 1..1 | ||||
Type | Reference(Patient) | ||||
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. | ||||
Summary | true | ||||
ExplanationOfBenefit.billablePeriod | |||||
Element Id | ExplanationOfBenefit.billablePeriod | ||||
Definition | The period for which charges are being submitted. | ||||
Short Display | Relevant time frame for the claim | ||||
Cardinality | 0..1 | ||||
Type | Period | ||||
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. | ||||
Summary | true | ||||
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. | ||||
ExplanationOfBenefit.created | |||||
Element Id | ExplanationOfBenefit.created | ||||
Definition | The date this resource was created. | ||||
Short Display | Response creation date | ||||
Cardinality | 1..1 | ||||
Type | dateTime | ||||
Requirements | Need to record a timestamp for use by both the recipient and the issuer. | ||||
Summary | true | ||||
ExplanationOfBenefit.enterer | |||||
Element Id | ExplanationOfBenefit.enterer | ||||
Definition | Individual who created the claim, predetermination or preauthorization. | ||||
Short Display | Author of the claim | ||||
Cardinality | 0..1 | ||||
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | ||||
Requirements | Some jurisdictions require the contact information for personnel completing claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.insurer | |||||
Element Id | ExplanationOfBenefit.insurer | ||||
Definition | The party responsible for authorization, adjudication and reimbursement. | ||||
Short Display | Party responsible for reimbursement | ||||
Cardinality | 0..1 | ||||
Type | Reference(Organization) | ||||
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. | ||||
Summary | true | ||||
ExplanationOfBenefit.provider | |||||
Element Id | ExplanationOfBenefit.provider | ||||
Definition | The provider which is responsible for the claim, predetermination or preauthorization. | ||||
Short Display | Party responsible for the claim | ||||
Cardinality | 0..1 | ||||
Type | Reference(Practitioner | PractitionerRole | Organization) | ||||
Summary | true | ||||
Comments | Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner. | ||||
ExplanationOfBenefit.priority | |||||
Element Id | ExplanationOfBenefit.priority | ||||
Definition | The provider-required urgency of processing the request. Typical values include: stat, normal deferred. | ||||
Short Display | Desired processing urgency | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Process Priority Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. | ||||
Summary | false | ||||
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request. | ||||
ExplanationOfBenefit.fundsReserveRequested | |||||
Element Id | ExplanationOfBenefit.fundsReserveRequested | ||||
Definition | A code to indicate whether and for whom funds are to be reserved for future claims. | ||||
Short Display | For whom to reserve funds | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Funds Reservation Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested. | ||||
Alternate Names | Fund pre-allocation | ||||
Summary | false | ||||
Comments | This field is only used for preauthorizations. | ||||
ExplanationOfBenefit.fundsReserve | |||||
Element Id | ExplanationOfBenefit.fundsReserve | ||||
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | ||||
Short Display | Funds reserved status | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Funds Reservation Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. | ||||
Summary | false | ||||
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. | ||||
ExplanationOfBenefit.related | |||||
Element Id | ExplanationOfBenefit.related | ||||
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | ||||
Short Display | Prior or corollary claims | ||||
Cardinality | 0..* | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Summary | false | ||||
Comments | For example, for the original treatment and follow-up exams. | ||||
ExplanationOfBenefit.related.claim | |||||
Element Id | ExplanationOfBenefit.related.claim | ||||
Definition | Reference to a related claim. | ||||
Short Display | Reference to the related claim | ||||
Cardinality | 0..1 | ||||
Type | Reference(Claim) | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Summary | false | ||||
ExplanationOfBenefit.related.relationship | |||||
Element Id | ExplanationOfBenefit.related.relationship | ||||
Definition | A code to convey how the claims are related. | ||||
Short Display | How the reference claim is related | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Related Claim Relationship Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Some insurers need a declaration of the type of relationship. | ||||
Summary | false | ||||
Comments | For example, prior claim or umbrella. | ||||
ExplanationOfBenefit.related.reference | |||||
Element Id | ExplanationOfBenefit.related.reference | ||||
Definition | An alternate organizational reference to the case or file to which this particular claim pertains. | ||||
Short Display | File or case reference | ||||
Cardinality | 0..1 | ||||
Type | Identifier | ||||
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. | ||||
Summary | false | ||||
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number. | ||||
ExplanationOfBenefit.prescription | |||||
Element Id | ExplanationOfBenefit.prescription | ||||
Definition | Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments. | ||||
Short Display | Prescription authorizing services or products | ||||
Cardinality | 0..1 | ||||
Type | Reference(MedicationRequest | VisionPrescription) | ||||
Requirements | Required to authorize the dispensing of controlled substances and devices. | ||||
Summary | false | ||||
ExplanationOfBenefit.originalPrescription | |||||
Element Id | ExplanationOfBenefit.originalPrescription | ||||
Definition | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | ||||
Short Display | Original prescription if superceded by fulfiller | ||||
Cardinality | 0..1 | ||||
Type | Reference(MedicationRequest) | ||||
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. | ||||
Summary | false | ||||
Comments | 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 prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'. | ||||
ExplanationOfBenefit.event | |||||
Element Id | ExplanationOfBenefit.event | ||||
Definition | Information code for an event with a corresponding date or period. | ||||
Short Display | Event information | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.event.type | |||||
Element Id | ExplanationOfBenefit.event.type | ||||
Definition | A coded event such as when a service is expected or a card printed. | ||||
Short Display | Specific event | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Dates Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Summary | false | ||||
ExplanationOfBenefit.event.when[x] | |||||
Element Id | ExplanationOfBenefit.event.when[x] | ||||
Definition | A date or period in the past or future indicating when the event occurred or is expectd to occur. | ||||
Short Display | Occurance date or period | ||||
Cardinality | 1..1 | ||||
Type | dateTime|Period | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Summary | false | ||||
ExplanationOfBenefit.payee | |||||
Element Id | ExplanationOfBenefit.payee | ||||
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy. | ||||
Short Display | Recipient of benefits payable | ||||
Cardinality | 0..1 | ||||
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. | ||||
Summary | false | ||||
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead. | ||||
ExplanationOfBenefit.payee.type | |||||
Element Id | ExplanationOfBenefit.payee.type | ||||
Definition | Type of Party to be reimbursed: Subscriber, provider, other. | ||||
Short Display | Category of recipient | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Claim Payee Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. | ||||
Summary | false | ||||
ExplanationOfBenefit.payee.party | |||||
Element Id | ExplanationOfBenefit.payee.party | ||||
Definition | Reference to the individual or organization to whom any payment will be made. | ||||
Short Display | Recipient reference | ||||
Cardinality | 0..1 | ||||
Type | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | ||||
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'. | ||||
Summary | false | ||||
Comments | Not required if the payee is 'subscriber' or 'provider'. | ||||
ExplanationOfBenefit.referral | |||||
Element Id | ExplanationOfBenefit.referral | ||||
Definition | The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services. | ||||
Short Display | Treatment Referral | ||||
Cardinality | 0..1 | ||||
Type | Reference(ServiceRequest) | ||||
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services. | ||||
Summary | false | ||||
Comments | The referral resource which lists the date, practitioner, reason and other supporting information. | ||||
ExplanationOfBenefit.encounter | |||||
Element Id | ExplanationOfBenefit.encounter | ||||
Definition | Healthcare encounters related to this claim. | ||||
Short Display | Encounters associated with the listed treatments | ||||
Cardinality | 0..* | ||||
Type | Reference(Encounter) | ||||
Requirements | Used in some jurisdictions to link clinical events to claim items. | ||||
Summary | false | ||||
ExplanationOfBenefit.facility | |||||
Element Id | ExplanationOfBenefit.facility | ||||
Definition | Facility where the services were provided. | ||||
Short Display | Servicing Facility | ||||
Cardinality | 0..1 | ||||
Type | Reference(Location | Organization) | ||||
Requirements | Insurance adjudication can be dependant on where services were delivered. | ||||
Summary | false | ||||
ExplanationOfBenefit.claim | |||||
Element Id | ExplanationOfBenefit.claim | ||||
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | ||||
Short Display | Claim reference | ||||
Cardinality | 0..1 | ||||
Type | Reference(Claim) | ||||
Requirements | To provide a link to the original adjudication request. | ||||
Summary | false | ||||
ExplanationOfBenefit.claimResponse | |||||
Element Id | ExplanationOfBenefit.claimResponse | ||||
Definition | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | ||||
Short Display | Claim response reference | ||||
Cardinality | 0..1 | ||||
Type | Reference(ClaimResponse) | ||||
Requirements | To provide a link to the original adjudication response. | ||||
Summary | false | ||||
ExplanationOfBenefit.outcome | |||||
Element Id | ExplanationOfBenefit.outcome | ||||
Definition | The outcome of the claim, predetermination, or preauthorization processing. | ||||
Short Display | queued | complete | error | partial | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Claim Processing Codes (Required) | ||||
Type | code | ||||
Requirements | To advise the requestor of an overall processing outcome. | ||||
Summary | true | ||||
Comments | The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete). | ||||
ExplanationOfBenefit.decision | |||||
Element Id | ExplanationOfBenefit.decision | ||||
Definition | The result of the claim, predetermination, or preauthorization adjudication. | ||||
Short Display | Result of the adjudication | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Claim Adjudication Decision Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To advise the requestor of the result of the adjudication process. | ||||
Summary | true | ||||
Comments | The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial). | ||||
ExplanationOfBenefit.disposition | |||||
Element Id | ExplanationOfBenefit.disposition | ||||
Definition | A human readable description of the status of the adjudication. | ||||
Short Display | Disposition Message | ||||
Cardinality | 0..1 | ||||
Type | string | ||||
Requirements | Provided for user display. | ||||
Summary | false | ||||
ExplanationOfBenefit.preAuthRef | |||||
Element Id | ExplanationOfBenefit.preAuthRef | ||||
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication. | ||||
Short Display | Preauthorization reference | ||||
Cardinality | 0..* | ||||
Type | string | ||||
Requirements | On subsequent claims, the insurer may require the provider to quote this value. | ||||
Summary | false | ||||
Comments | This value is only present on preauthorization adjudications. | ||||
ExplanationOfBenefit.preAuthRefPeriod | |||||
Element Id | ExplanationOfBenefit.preAuthRefPeriod | ||||
Definition | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | ||||
Short Display | Preauthorization in-effect period | ||||
Cardinality | 0..* | ||||
Type | Period | ||||
Requirements | On subsequent claims, the insurer may require the provider to quote this value. | ||||
Summary | false | ||||
Comments | This value is only present on preauthorization adjudications. | ||||
ExplanationOfBenefit.diagnosisRelatedGroup | |||||
Element Id | ExplanationOfBenefit.diagnosisRelatedGroup | ||||
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system. | ||||
Short Display | Package billing code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Diagnosis Related Group Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code. | ||||
Summary | false | ||||
Comments | For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event. | ||||
ExplanationOfBenefit.careTeam | |||||
Element Id | ExplanationOfBenefit.careTeam | ||||
Definition | The members of the team who provided the products and services. | ||||
Short Display | Care Team members | ||||
Cardinality | 0..* | ||||
Requirements | Common to identify the responsible and supporting practitioners. | ||||
Summary | false | ||||
ExplanationOfBenefit.careTeam.sequence | |||||
Element Id | ExplanationOfBenefit.careTeam.sequence | ||||
Definition | A number to uniquely identify care team entries. | ||||
Short Display | Order of care team | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. | ||||
Summary | false | ||||
ExplanationOfBenefit.careTeam.provider | |||||
Element Id | ExplanationOfBenefit.careTeam.provider | ||||
Definition | Member of the team who provided the product or service. | ||||
Short Display | Practitioner or organization | ||||
Cardinality | 1..1 | ||||
Type | Reference(Practitioner | PractitionerRole | Organization) | ||||
Requirements | Often a regulatory requirement to specify the responsible provider. | ||||
Summary | false | ||||
ExplanationOfBenefit.careTeam.responsible | |||||
Element Id | ExplanationOfBenefit.careTeam.responsible | ||||
Definition | The party who is billing and/or responsible for the claimed products or services. | ||||
Short Display | Indicator of the lead practitioner | ||||
Cardinality | 0..1 | ||||
Type | boolean | ||||
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual. | ||||
Summary | false | ||||
Comments | Responsible might not be required when there is only a single provider listed. | ||||
ExplanationOfBenefit.careTeam.role | |||||
Element Id | ExplanationOfBenefit.careTeam.role | ||||
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. | ||||
Short Display | Function within the team | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Claim Care Team Role Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member. | ||||
Summary | false | ||||
Comments | Role might not be required when there is only a single provider listed. | ||||
ExplanationOfBenefit.careTeam.specialty | |||||
Element Id | ExplanationOfBenefit.careTeam.specialty | ||||
Definition | The specialization of the practitioner or provider which is applicable for this service. | ||||
Short Display | Practitioner or provider specialization | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Provider Qualification Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Need to specify which specialization a practitioner or provider acting under when delivering the product or service. | ||||
Summary | false | ||||
ExplanationOfBenefit.supportingInfo | |||||
Element Id | ExplanationOfBenefit.supportingInfo | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short Display | Supporting information | ||||
Cardinality | 0..* | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Summary | false | ||||
Comments | Often there are multiple jurisdiction specific valuesets which are required. | ||||
ExplanationOfBenefit.supportingInfo.sequence | |||||
Element Id | ExplanationOfBenefit.supportingInfo.sequence | ||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short Display | Information instance identifier | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Summary | false | ||||
ExplanationOfBenefit.supportingInfo.category | |||||
Element Id | ExplanationOfBenefit.supportingInfo.category | ||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short Display | Classification of the supplied information | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Claim Information Category Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Summary | false | ||||
Comments | This may contain a category for the local bill type codes. | ||||
ExplanationOfBenefit.supportingInfo.code | |||||
Element Id | ExplanationOfBenefit.supportingInfo.code | ||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short Display | Type of information | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Exception Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Required to identify the kind of additional information. | ||||
Summary | false | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
ExplanationOfBenefit.supportingInfo.timing[x] | |||||
Element Id | ExplanationOfBenefit.supportingInfo.timing[x] | ||||
Definition | The date when or period to which this information refers. | ||||
Short Display | When it occurred | ||||
Cardinality | 0..1 | ||||
Type | date|Period | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Summary | false | ||||
ExplanationOfBenefit.supportingInfo.value[x] | |||||
Element Id | ExplanationOfBenefit.supportingInfo.value[x] | ||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short Display | Data to be provided | ||||
Cardinality | 0..1 | ||||
Type | boolean|string|Quantity|Attachment|Reference(Any)|Identifier | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Summary | false | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
ExplanationOfBenefit.supportingInfo.reason | |||||
Element Id | ExplanationOfBenefit.supportingInfo.reason | ||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short Display | Explanation for the information | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Missing Tooth Reason Codes (Example) | ||||
Type | Coding | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Summary | false | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
ExplanationOfBenefit.diagnosis | |||||
Element Id | ExplanationOfBenefit.diagnosis | ||||
Definition | Information about diagnoses relevant to the claim items. | ||||
Short Display | Pertinent diagnosis information | ||||
Cardinality | 0..* | ||||
Requirements | Required for the adjudication by provided context for the services and product listed. | ||||
Summary | false | ||||
ExplanationOfBenefit.diagnosis.sequence | |||||
Element Id | ExplanationOfBenefit.diagnosis.sequence | ||||
Definition | A number to uniquely identify diagnosis entries. | ||||
Short Display | Diagnosis instance identifier | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. | ||||
Summary | false | ||||
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc. | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | |||||
Element Id | ExplanationOfBenefit.diagnosis.diagnosis[x] | ||||
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition. | ||||
Short Display | Nature of illness or problem | ||||
Cardinality | 1..1 | ||||
Terminology Binding | ICD-10 Codes (Example) | ||||
Type | CodeableConcept|Reference(Condition) | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Provides health context for the evaluation of the products and/or services. | ||||
Summary | false | ||||
ExplanationOfBenefit.diagnosis.type | |||||
Element Id | ExplanationOfBenefit.diagnosis.type | ||||
Definition | When the condition was observed or the relative ranking. | ||||
Short Display | Timing or nature of the diagnosis | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Diagnosis Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge. | ||||
Summary | false | ||||
Comments | For example: admitting, primary, secondary, discharge. | ||||
ExplanationOfBenefit.diagnosis.onAdmission | |||||
Element Id | ExplanationOfBenefit.diagnosis.onAdmission | ||||
Definition | Indication of whether the diagnosis was present on admission to a facility. | ||||
Short Display | Present on admission | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Diagnosis on Admission Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure | |||||
Element Id | ExplanationOfBenefit.procedure | ||||
Definition | Procedures performed on the patient relevant to the billing items with the claim. | ||||
Short Display | Clinical procedures performed | ||||
Cardinality | 0..* | ||||
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure.sequence | |||||
Element Id | ExplanationOfBenefit.procedure.sequence | ||||
Definition | A number to uniquely identify procedure entries. | ||||
Short Display | Procedure instance identifier | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to provide a mechanism to link to claim details. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure.type | |||||
Element Id | ExplanationOfBenefit.procedure.type | ||||
Definition | When the condition was observed or the relative ranking. | ||||
Short Display | Category of Procedure | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Procedure Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure.date | |||||
Element Id | ExplanationOfBenefit.procedure.date | ||||
Definition | Date and optionally time the procedure was performed. | ||||
Short Display | When the procedure was performed | ||||
Cardinality | 0..1 | ||||
Type | dateTime | ||||
Requirements | Required for auditing purposes. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure.procedure[x] | |||||
Element Id | ExplanationOfBenefit.procedure.procedure[x] | ||||
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed. | ||||
Short Display | Specific clinical procedure | ||||
Cardinality | 1..1 | ||||
Terminology Binding | ICD-10 Procedure Codes (Example) | ||||
Type | CodeableConcept|Reference(Procedure) | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | This identifies the actual clinical procedure. | ||||
Summary | false | ||||
ExplanationOfBenefit.procedure.udi | |||||
Element Id | ExplanationOfBenefit.procedure.udi | ||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short Display | Unique device identifier | ||||
Cardinality | 0..* | ||||
Type | Reference(Device) | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Summary | false | ||||
ExplanationOfBenefit.precedence | |||||
Element Id | ExplanationOfBenefit.precedence | ||||
Definition | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | ||||
Short Display | Precedence (primary, secondary, etc.) | ||||
Cardinality | 0..1 | ||||
Type | positiveInt | ||||
Requirements | Needed to coordinate between multiple EOBs for the same suite of services. | ||||
Summary | false | ||||
ExplanationOfBenefit.insurance | |||||
Element Id | ExplanationOfBenefit.insurance | ||||
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim. | ||||
Short Display | Patient insurance information | ||||
Cardinality | 0..* | ||||
Requirements | At least one insurer is required for a claim to be a claim. | ||||
Summary | true | ||||
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. | ||||
ExplanationOfBenefit.insurance.focal | |||||
Element Id | ExplanationOfBenefit.insurance.focal | ||||
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. | ||||
Short Display | Coverage to be used for adjudication | ||||
Cardinality | 1..1 | ||||
Type | boolean | ||||
Requirements | To identify which coverage in the list is being used to adjudicate this claim. | ||||
Summary | true | ||||
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. | ||||
ExplanationOfBenefit.insurance.coverage | |||||
Element Id | ExplanationOfBenefit.insurance.coverage | ||||
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. | ||||
Short Display | Insurance information | ||||
Cardinality | 1..1 | ||||
Type | Reference(Coverage) | ||||
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. | ||||
Summary | true | ||||
ExplanationOfBenefit.insurance.preAuthRef | |||||
Element Id | ExplanationOfBenefit.insurance.preAuthRef | ||||
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. | ||||
Short Display | Prior authorization reference number | ||||
Cardinality | 0..* | ||||
Type | string | ||||
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization. | ||||
Summary | false | ||||
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier. | ||||
ExplanationOfBenefit.accident | |||||
Element Id | ExplanationOfBenefit.accident | ||||
Definition | Details of a accident which resulted in injuries which required the products and services listed in the claim. | ||||
Short Display | Details of the event | ||||
Cardinality | 0..1 | ||||
Requirements | When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance. | ||||
Summary | false | ||||
ExplanationOfBenefit.accident.date | |||||
Element Id | ExplanationOfBenefit.accident.date | ||||
Definition | Date of an accident event related to the products and services contained in the claim. | ||||
Short Display | When the incident occurred | ||||
Cardinality | 0..1 | ||||
Type | date | ||||
Requirements | Required for audit purposes and adjudication. | ||||
Summary | false | ||||
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe. | ||||
ExplanationOfBenefit.accident.type | |||||
Element Id | ExplanationOfBenefit.accident.type | ||||
Definition | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. | ||||
Short Display | The nature of the accident | ||||
Cardinality | 0..1 | ||||
Terminology Binding | ActIncidentCode (Extensible) | ||||
Type | CodeableConcept | ||||
Requirements | Coverage may be dependant on the type of accident. | ||||
Summary | false | ||||
ExplanationOfBenefit.accident.location[x] | |||||
Element Id | ExplanationOfBenefit.accident.location[x] | ||||
Definition | The physical location of the accident event. | ||||
Short Display | Where the event occurred | ||||
Cardinality | 0..1 | ||||
Type | Address|Reference(Location) | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Required for audit purposes and determination of applicable insurance liability. | ||||
Summary | false | ||||
ExplanationOfBenefit.patientPaid | |||||
Element Id | ExplanationOfBenefit.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.item | |||||
Element Id | ExplanationOfBenefit.item | ||||
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. | ||||
Short Display | Product or service provided | ||||
Cardinality | 0..* | ||||
Requirements | The items to be processed for adjudication. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.sequence | |||||
Element Id | ExplanationOfBenefit.item.sequence | ||||
Definition | A number to uniquely identify item entries. | ||||
Short Display | Item instance identifier | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.careTeamSequence | |||||
Element Id | ExplanationOfBenefit.item.careTeamSequence | ||||
Definition | Care team members related to this service or product. | ||||
Short Display | Applicable care team members | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Need to identify the individuals and their roles in the provision of the product or service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.diagnosisSequence | |||||
Element Id | ExplanationOfBenefit.item.diagnosisSequence | ||||
Definition | Diagnoses applicable for this service or product. | ||||
Short Display | Applicable diagnoses | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Need to related the product or service to the associated diagnoses. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.procedureSequence | |||||
Element Id | ExplanationOfBenefit.item.procedureSequence | ||||
Definition | Procedures applicable for this service or product. | ||||
Short Display | Applicable procedures | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Need to provide any listed specific procedures to support the product or service being claimed. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.informationSequence | |||||
Element Id | ExplanationOfBenefit.item.informationSequence | ||||
Definition | Exceptions, special conditions and supporting information applicable for this service or product. | ||||
Short Display | Applicable exception and supporting information | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Need to reference the supporting information items that relate directly to this product or service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.traceNumber | |||||
Element Id | ExplanationOfBenefit.item.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.revenue | |||||
Element Id | ExplanationOfBenefit.item.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.category | |||||
Element Id | ExplanationOfBenefit.item.category | ||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short Display | Benefit classification | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Benefit Category Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Summary | false | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
ExplanationOfBenefit.item.productOrService | |||||
Element Id | ExplanationOfBenefit.item.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.item.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.item.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.item.request | |||||
Element Id | ExplanationOfBenefit.item.request | ||||
Definition | Request or Referral for Goods or Service to be rendered. | ||||
Short Display | Request or Referral for Service | ||||
Cardinality | 0..* | ||||
Type | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | ||||
Requirements | May identify the service to be provided or provider authorization for the service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.modifier | |||||
Element Id | ExplanationOfBenefit.item.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Product or service billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
ExplanationOfBenefit.item.programCode | |||||
Element Id | ExplanationOfBenefit.item.programCode | ||||
Definition | Identifies the program under which this may be recovered. | ||||
Short Display | Program the product or service is provided under | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Program Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Summary | false | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
ExplanationOfBenefit.item.serviced[x] | |||||
Element Id | ExplanationOfBenefit.item.serviced[x] | ||||
Definition | The date or dates when the service or product was supplied, performed or completed. | ||||
Short Display | Date or dates of service or product delivery | ||||
Cardinality | 0..1 | ||||
Type | date|Period | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.location[x] | |||||
Element Id | ExplanationOfBenefit.item.location[x] | ||||
Definition | Where the product or service was provided. | ||||
Short Display | Place of service or where product was supplied | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Service Place Codes (Example) | ||||
Type | CodeableConcept|Address|Reference(Location) | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.patientPaid | |||||
Element Id | ExplanationOfBenefit.item.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.quantity | |||||
Element Id | ExplanationOfBenefit.item.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.unitPrice | |||||
Element Id | ExplanationOfBenefit.item.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.factor | |||||
Element Id | ExplanationOfBenefit.item.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.item.tax | |||||
Element Id | ExplanationOfBenefit.item.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.net | |||||
Element Id | ExplanationOfBenefit.item.net | ||||
Definition | The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.item.udi | |||||
Element Id | ExplanationOfBenefit.item.udi | ||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short Display | Unique device identifier | ||||
Cardinality | 0..* | ||||
Type | Reference(Device) | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.bodySite | |||||
Element Id | ExplanationOfBenefit.item.bodySite | ||||
Definition | Physical location where the service is performed or applies. | ||||
Short Display | Anatomical location | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.item.bodySite.site | |||||
Element Id | ExplanationOfBenefit.item.bodySite.site | ||||
Definition | Physical service site on the patient (limb, tooth, etc.). | ||||
Short Display | Location | ||||
Cardinality | 1..* | ||||
Terminology Binding | Oral Site Codes (Example) | ||||
Type | CodeableReference(BodyStructure) | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Summary | false | ||||
Comments | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. | ||||
ExplanationOfBenefit.item.bodySite.subSite | |||||
Element Id | ExplanationOfBenefit.item.bodySite.subSite | ||||
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s). | ||||
Short Display | Sub-location | ||||
Cardinality | 0..* | ||||
Terminology Binding | Surface Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.encounter | |||||
Element Id | ExplanationOfBenefit.item.encounter | ||||
Definition | Healthcare encounters related to this claim. | ||||
Short Display | Encounters associated with the listed treatments | ||||
Cardinality | 0..* | ||||
Type | Reference(Encounter) | ||||
Requirements | Used in some jurisdictions to link clinical events to claim items. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.noteNumber | |||||
Element Id | ExplanationOfBenefit.item.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.item.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Adjudication results | ||||
Cardinality | 0..1 | ||||
Summary | false | ||||
ExplanationOfBenefit.item.reviewOutcome.decision | |||||
Element Id | ExplanationOfBenefit.item.reviewOutcome.decision | ||||
Definition | The result of the claim, predetermination, or preauthorization adjudication. | ||||
Short Display | Result of the adjudication | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Claim Adjudication Decision Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To advise the requestor of the result of the adjudication process. | ||||
Summary | false | ||||
Comments | The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial). | ||||
ExplanationOfBenefit.item.reviewOutcome.reason | |||||
Element Id | ExplanationOfBenefit.item.reviewOutcome.reason | ||||
Definition | The reasons for the result of the claim, predetermination, or preauthorization adjudication. | ||||
Short Display | Reason for result of the adjudication | ||||
Cardinality | 0..* | ||||
Terminology Binding | Claim Adjudication Decision Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To advise the requestor of the contributors to the result of the adjudication process. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.reviewOutcome.preAuthRef | |||||
Element Id | ExplanationOfBenefit.item.reviewOutcome.preAuthRef | ||||
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication. | ||||
Short Display | Preauthorization reference | ||||
Cardinality | 0..1 | ||||
Type | string | ||||
Requirements | On subsequent claims, the insurer may require the provider to quote this value. | ||||
Summary | false | ||||
Comments | This value is only present on preauthorization adjudications. | ||||
ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod | |||||
Element Id | ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod | ||||
Definition | The time frame during which this authorization is effective. | ||||
Short Display | Preauthorization reference effective period | ||||
Cardinality | 0..1 | ||||
Type | Period | ||||
Requirements | To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.adjudication | |||||
Element Id | ExplanationOfBenefit.item.adjudication | ||||
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. | ||||
Short Display | Adjudication details | ||||
Cardinality | 0..* | ||||
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.adjudication.category | |||||
Element Id | ExplanationOfBenefit.item.adjudication.category | ||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short Display | Type of adjudication information | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Adjudication Value Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Summary | false | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
ExplanationOfBenefit.item.adjudication.reason | |||||
Element Id | ExplanationOfBenefit.item.adjudication.reason | ||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short Display | Explanation of adjudication outcome | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Adjudication Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Summary | false | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
ExplanationOfBenefit.item.adjudication.amount | |||||
Element Id | ExplanationOfBenefit.item.adjudication.amount | ||||
Definition | Monetary amount associated with the category. | ||||
Short Display | Monetary amount | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Most adjudication categories convey a monetary amount. | ||||
Summary | false | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
ExplanationOfBenefit.item.adjudication.quantity | |||||
Element Id | ExplanationOfBenefit.item.adjudication.quantity | ||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short Display | Non-monitary value | ||||
Cardinality | 0..1 | ||||
Type | Quantity | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Summary | false | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
ExplanationOfBenefit.item.detail | |||||
Element Id | ExplanationOfBenefit.item.detail | ||||
Definition | Second-tier of goods and services. | ||||
Short Display | Additional items | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.sequence | |||||
Element Id | ExplanationOfBenefit.item.detail.sequence | ||||
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | ||||
Short Display | Product or service provided | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | The items to be processed for adjudication. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.traceNumber | |||||
Element Id | ExplanationOfBenefit.item.detail.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.revenue | |||||
Element Id | ExplanationOfBenefit.item.detail.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.category | |||||
Element Id | ExplanationOfBenefit.item.detail.category | ||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short Display | Benefit classification | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Benefit Category Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Summary | false | ||||
Comments | Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
ExplanationOfBenefit.item.detail.productOrService | |||||
Element Id | ExplanationOfBenefit.item.detail.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.item.detail.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.item.detail.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.modifier | |||||
Element Id | ExplanationOfBenefit.item.detail.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Service/Product billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
ExplanationOfBenefit.item.detail.programCode | |||||
Element Id | ExplanationOfBenefit.item.detail.programCode | ||||
Definition | Identifies the program under which this may be recovered. | ||||
Short Display | Program the product or service is provided under | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Program Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Summary | false | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
ExplanationOfBenefit.item.detail.patientPaid | |||||
Element Id | ExplanationOfBenefit.item.detail.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.quantity | |||||
Element Id | ExplanationOfBenefit.item.detail.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.unitPrice | |||||
Element Id | ExplanationOfBenefit.item.detail.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.factor | |||||
Element Id | ExplanationOfBenefit.item.detail.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.item.detail.tax | |||||
Element Id | ExplanationOfBenefit.item.detail.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.net | |||||
Element Id | ExplanationOfBenefit.item.detail.net | ||||
Definition | The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.item.detail.udi | |||||
Element Id | ExplanationOfBenefit.item.detail.udi | ||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short Display | Unique device identifier | ||||
Cardinality | 0..* | ||||
Type | Reference(Device) | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.noteNumber | |||||
Element Id | ExplanationOfBenefit.item.detail.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.item.detail.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Detail level adjudication results | ||||
Cardinality | 0..1 | ||||
Type | See ExplanationOfBenefit.item.reviewOutcome | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.adjudication | |||||
Element Id | ExplanationOfBenefit.item.detail.adjudication | ||||
Definition | The adjudication results. | ||||
Short Display | Detail level adjudication details | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail | ||||
Definition | Third-tier of goods and services. | ||||
Short Display | Additional items | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.sequence | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.sequence | ||||
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | ||||
Short Display | Product or service provided | ||||
Cardinality | 1..1 | ||||
Type | positiveInt | ||||
Requirements | The items to be processed for adjudication. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.traceNumber | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.category | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.category | ||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short Display | Benefit classification | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Benefit Category Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Summary | false | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Service/Product billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.programCode | ||||
Definition | Identifies the program under which this may be recovered. | ||||
Short Display | Program the product or service is provided under | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Program Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Summary | false | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
ExplanationOfBenefit.item.detail.subDetail.patientPaid | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.quantity | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.unitPrice | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.factor | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.item.detail.subDetail.tax | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.net | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.net | ||||
Definition | The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.item.detail.subDetail.udi | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.udi | ||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short Display | Unique device identifier | ||||
Cardinality | 0..* | ||||
Type | Reference(Device) | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.noteNumber | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Subdetail level adjudication results | ||||
Cardinality | 0..1 | ||||
Type | See ExplanationOfBenefit.item.reviewOutcome | ||||
Summary | false | ||||
ExplanationOfBenefit.item.detail.subDetail.adjudication | |||||
Element Id | ExplanationOfBenefit.item.detail.subDetail.adjudication | ||||
Definition | The adjudication results. | ||||
Short Display | Subdetail level adjudication details | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem | |||||
Element Id | ExplanationOfBenefit.addItem | ||||
Definition | The first-tier service adjudications for payor added product or service lines. | ||||
Short Display | Insurer added line items | ||||
Cardinality | 0..* | ||||
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.itemSequence | |||||
Element Id | ExplanationOfBenefit.addItem.itemSequence | ||||
Definition | Claim items which this service line is intended to replace. | ||||
Short Display | Item sequence number | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides references to the claim items. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detailSequence | |||||
Element Id | ExplanationOfBenefit.addItem.detailSequence | ||||
Definition | The sequence number of the details within the claim item which this line is intended to replace. | ||||
Short Display | Detail sequence number | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides references to the claim details within the claim item. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.subDetailSequence | |||||
Element Id | ExplanationOfBenefit.addItem.subDetailSequence | ||||
Definition | The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace. | ||||
Short Display | Subdetail sequence number | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides references to the claim sub-details within the claim detail. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.traceNumber | |||||
Element Id | ExplanationOfBenefit.addItem.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.provider | |||||
Element Id | ExplanationOfBenefit.addItem.provider | ||||
Definition | The providers who are authorized for the services rendered to the patient. | ||||
Short Display | Authorized providers | ||||
Cardinality | 0..* | ||||
Type | Reference(Practitioner | PractitionerRole | Organization) | ||||
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.revenue | |||||
Element Id | ExplanationOfBenefit.addItem.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.productOrService | |||||
Element Id | ExplanationOfBenefit.addItem.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.addItem.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.addItem.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.request | |||||
Element Id | ExplanationOfBenefit.addItem.request | ||||
Definition | Request or Referral for Goods or Service to be rendered. | ||||
Short Display | Request or Referral for Service | ||||
Cardinality | 0..* | ||||
Type | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | ||||
Requirements | May identify the service to be provided or provider authorization for the service. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.modifier | |||||
Element Id | ExplanationOfBenefit.addItem.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Service/Product billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
ExplanationOfBenefit.addItem.programCode | |||||
Element Id | ExplanationOfBenefit.addItem.programCode | ||||
Definition | Identifies the program under which this may be recovered. | ||||
Short Display | Program the product or service is provided under | ||||
Cardinality | 0..* | ||||
Terminology Binding | Example Program Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Summary | false | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
ExplanationOfBenefit.addItem.serviced[x] | |||||
Element Id | ExplanationOfBenefit.addItem.serviced[x] | ||||
Definition | The date or dates when the service or product was supplied, performed or completed. | ||||
Short Display | Date or dates of service or product delivery | ||||
Cardinality | 0..1 | ||||
Type | date|Period | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.location[x] | |||||
Element Id | ExplanationOfBenefit.addItem.location[x] | ||||
Definition | Where the product or service was provided. | ||||
Short Display | Place of service or where product was supplied | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Service Place Codes (Example) | ||||
Type | CodeableConcept|Address|Reference(Location) | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.patientPaid | |||||
Element Id | ExplanationOfBenefit.addItem.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.quantity | |||||
Element Id | ExplanationOfBenefit.addItem.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.unitPrice | |||||
Element Id | ExplanationOfBenefit.addItem.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.factor | |||||
Element Id | ExplanationOfBenefit.addItem.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.addItem.tax | |||||
Element Id | ExplanationOfBenefit.addItem.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.net | |||||
Element Id | ExplanationOfBenefit.addItem.net | ||||
Definition | The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.addItem.bodySite | |||||
Element Id | ExplanationOfBenefit.addItem.bodySite | ||||
Definition | Physical location where the service is performed or applies. | ||||
Short Display | Anatomical location | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.bodySite.site | |||||
Element Id | ExplanationOfBenefit.addItem.bodySite.site | ||||
Definition | Physical service site on the patient (limb, tooth, etc.). | ||||
Short Display | Location | ||||
Cardinality | 1..* | ||||
Terminology Binding | Oral Site Codes (Example) | ||||
Type | CodeableReference(BodyStructure) | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Summary | false | ||||
Comments | For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. | ||||
ExplanationOfBenefit.addItem.bodySite.subSite | |||||
Element Id | ExplanationOfBenefit.addItem.bodySite.subSite | ||||
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s). | ||||
Short Display | Sub-location | ||||
Cardinality | 0..* | ||||
Terminology Binding | Surface Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.noteNumber | |||||
Element Id | ExplanationOfBenefit.addItem.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.addItem.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Additem level adjudication results | ||||
Cardinality | 0..1 | ||||
Type | See ExplanationOfBenefit.item.reviewOutcome | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.adjudication | |||||
Element Id | ExplanationOfBenefit.addItem.adjudication | ||||
Definition | The adjudication results. | ||||
Short Display | Added items adjudication | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail | |||||
Element Id | ExplanationOfBenefit.addItem.detail | ||||
Definition | The second-tier service adjudications for payor added services. | ||||
Short Display | Insurer added line items | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.traceNumber | |||||
Element Id | ExplanationOfBenefit.addItem.detail.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.revenue | |||||
Element Id | ExplanationOfBenefit.addItem.detail.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.productOrService | |||||
Element Id | ExplanationOfBenefit.addItem.detail.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.addItem.detail.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.addItem.detail.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.modifier | |||||
Element Id | ExplanationOfBenefit.addItem.detail.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Service/Product billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
ExplanationOfBenefit.addItem.detail.patientPaid | |||||
Element Id | ExplanationOfBenefit.addItem.detail.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.quantity | |||||
Element Id | ExplanationOfBenefit.addItem.detail.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.unitPrice | |||||
Element Id | ExplanationOfBenefit.addItem.detail.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.factor | |||||
Element Id | ExplanationOfBenefit.addItem.detail.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.addItem.detail.tax | |||||
Element Id | ExplanationOfBenefit.addItem.detail.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.net | |||||
Element Id | ExplanationOfBenefit.addItem.detail.net | ||||
Definition | The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.addItem.detail.noteNumber | |||||
Element Id | ExplanationOfBenefit.addItem.detail.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.addItem.detail.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Additem detail level adjudication results | ||||
Cardinality | 0..1 | ||||
Type | See ExplanationOfBenefit.item.reviewOutcome | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.adjudication | |||||
Element Id | ExplanationOfBenefit.addItem.detail.adjudication | ||||
Definition | The adjudication results. | ||||
Short Display | Added items adjudication | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail | ||||
Definition | The third-tier service adjudications for payor added services. | ||||
Short Display | Insurer added line items | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.traceNumber | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.traceNumber | ||||
Definition | Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners. | ||||
Short Display | Number for tracking | ||||
Cardinality | 0..* | ||||
Type | Identifier | ||||
Requirements | Allows partners to uniquely identify components for tracking. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.revenue | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.revenue | ||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short Display | Revenue or cost center code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Revenue Center Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.productOrService | ||||
Definition | When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used. | ||||
Short Display | Billing, service, product, or drug code | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||
Summary | false | ||||
Comments | 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, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd | ||||
Definition | This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims. | ||||
Short Display | End of a range of codes | ||||
Cardinality | 0..1 | ||||
Terminology Binding | USCLS Codes (Example) | ||||
Type | CodeableConcept | ||||
Alternate Names | End of a range of Drug Code; Bill Code; Service Cod | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.modifier | ||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short Display | Service/Product billing modifiers | ||||
Cardinality | 0..* | ||||
Terminology Binding | Modifier type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Summary | false | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.patientPaid | ||||
Definition | The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services. | ||||
Short Display | Paid by the patient | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.quantity | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.quantity | ||||
Definition | The number of repetitions of a service or product. | ||||
Short Display | Count of products or services | ||||
Cardinality | 0..1 | ||||
Type | SimpleQuantity | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.unitPrice | ||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short Display | Fee, charge or cost per item | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.factor | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.factor | ||||
Definition | 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 amount. | ||||
Short Display | Price scaling factor | ||||
Cardinality | 0..1 | ||||
Type | decimal | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Summary | false | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
ExplanationOfBenefit.addItem.detail.subDetail.tax | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.tax | ||||
Definition | The total of taxes applicable for this product or service. | ||||
Short Display | Total tax | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Required when taxes are not embedded in the unit price or provided as a separate service. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.net | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.net | ||||
Definition | The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor. | ||||
Short Display | Total item cost | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Summary | false | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.noteNumber | ||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short Display | Applicable note numbers | ||||
Cardinality | 0..* | ||||
Type | positiveInt | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome | ||||
Definition | The high-level results of the adjudication if adjudication has been performed. | ||||
Short Display | Additem subdetail level adjudication results | ||||
Cardinality | 0..1 | ||||
Type | See ExplanationOfBenefit.item.reviewOutcome | ||||
Summary | false | ||||
ExplanationOfBenefit.addItem.detail.subDetail.adjudication | |||||
Element Id | ExplanationOfBenefit.addItem.detail.subDetail.adjudication | ||||
Definition | The adjudication results. | ||||
Short Display | Added items adjudication | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Summary | false | ||||
ExplanationOfBenefit.adjudication | |||||
Element Id | ExplanationOfBenefit.adjudication | ||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short Display | Header-level adjudication | ||||
Cardinality | 0..* | ||||
Type | See ExplanationOfBenefit.item.adjudication | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Summary | false | ||||
ExplanationOfBenefit.total | |||||
Element Id | ExplanationOfBenefit.total | ||||
Definition | Categorized monetary totals for the adjudication. | ||||
Short Display | Adjudication totals | ||||
Cardinality | 0..* | ||||
Requirements | To provide the requestor with financial totals by category for the adjudication. | ||||
Summary | true | ||||
Comments | Totals for amounts submitted, co-pays, benefits payable etc. | ||||
ExplanationOfBenefit.total.category | |||||
Element Id | ExplanationOfBenefit.total.category | ||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short Display | Type of adjudication information | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Adjudication Value Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to convey the type of total provided. | ||||
Summary | true | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
ExplanationOfBenefit.total.amount | |||||
Element Id | ExplanationOfBenefit.total.amount | ||||
Definition | Monetary total amount associated with the category. | ||||
Short Display | Financial total for the category | ||||
Cardinality | 1..1 | ||||
Type | Money | ||||
Requirements | Needed to convey the total monetary amount. | ||||
Summary | true | ||||
ExplanationOfBenefit.payment | |||||
Element Id | ExplanationOfBenefit.payment | ||||
Definition | Payment details for the adjudication of the claim. | ||||
Short Display | Payment Details | ||||
Cardinality | 0..1 | ||||
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made. | ||||
Summary | false | ||||
ExplanationOfBenefit.payment.type | |||||
Element Id | ExplanationOfBenefit.payment.type | ||||
Definition | Whether this represents partial or complete payment of the benefits payable. | ||||
Short Display | Partial or complete payment | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Example Payment Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | To advise the requestor when the insurer believes all payments to have been completed. | ||||
Summary | false | ||||
ExplanationOfBenefit.payment.adjustment | |||||
Element Id | ExplanationOfBenefit.payment.adjustment | ||||
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. | ||||
Short Display | Payment adjustment for non-claim issues | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | To advise the requestor of adjustments applied to the payment. | ||||
Summary | false | ||||
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider. | ||||
ExplanationOfBenefit.payment.adjustmentReason | |||||
Element Id | ExplanationOfBenefit.payment.adjustmentReason | ||||
Definition | Reason for the payment adjustment. | ||||
Short Display | Explanation for the variance | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Payment Adjustment Reason Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to clarify the monetary adjustment. | ||||
Summary | false | ||||
ExplanationOfBenefit.payment.date | |||||
Element Id | ExplanationOfBenefit.payment.date | ||||
Definition | Estimated date the payment will be issued or the actual issue date of payment. | ||||
Short Display | Expected date of payment | ||||
Cardinality | 0..1 | ||||
Type | date | ||||
Requirements | To advise the payee when payment can be expected. | ||||
Summary | false | ||||
ExplanationOfBenefit.payment.amount | |||||
Element Id | ExplanationOfBenefit.payment.amount | ||||
Definition | Benefits payable less any payment adjustment. | ||||
Short Display | Payable amount after adjustment | ||||
Cardinality | 0..1 | ||||
Type | Money | ||||
Requirements | Needed to provide the actual payment amount. | ||||
Summary | false | ||||
ExplanationOfBenefit.payment.identifier | |||||
Element Id | ExplanationOfBenefit.payment.identifier | ||||
Definition | Issuer's unique identifier for the payment instrument. | ||||
Short Display | Business identifier for the payment | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Cardinality | 0..1 | ||||
Type | Identifier | ||||
Requirements | Enable the receiver to reconcile when payment received. | ||||
Summary | false | ||||
Comments | For example: EFT number or check number. | ||||
ExplanationOfBenefit.formCode | |||||
Element Id | ExplanationOfBenefit.formCode | ||||
Definition | A code for the form to be used for printing the content. | ||||
Short Display | Printed form identifier | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Form Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to specify the specific form used for producing output for this response. | ||||
Summary | false | ||||
Comments | May be needed to identify specific jurisdictional forms. | ||||
ExplanationOfBenefit.form | |||||
Element Id | ExplanationOfBenefit.form | ||||
Definition | The actual form, by reference or inclusion, for printing the content or an EOB. | ||||
Short Display | Printed reference or actual form | ||||
Cardinality | 0..1 | ||||
Type | Attachment | ||||
Requirements | Needed to include the specific form used for producing output for this response. | ||||
Summary | false | ||||
Comments | Needed to permit insurers to include the actual form. | ||||
ExplanationOfBenefit.processNote | |||||
Element Id | ExplanationOfBenefit.processNote | ||||
Definition | A note that describes or explains adjudication results in a human readable form. | ||||
Short Display | Note concerning adjudication | ||||
Cardinality | 0..* | ||||
Requirements | Provides the insurer specific textual explanations associated with the processing. | ||||
Summary | false | ||||
ExplanationOfBenefit.processNote.number | |||||
Element Id | ExplanationOfBenefit.processNote.number | ||||
Definition | A number to uniquely identify a note entry. | ||||
Short Display | Note instance identifier | ||||
Cardinality | 0..1 | ||||
Type | positiveInt | ||||
Requirements | Necessary to provide a mechanism to link from adjudications. | ||||
Summary | false | ||||
ExplanationOfBenefit.processNote.type | |||||
Element Id | ExplanationOfBenefit.processNote.type | ||||
Definition | The business purpose of the note text. | ||||
Short Display | Note purpose | ||||
Cardinality | 0..1 | ||||
Terminology Binding | NoteType (Extensible) | ||||
Type | CodeableConcept | ||||
Requirements | To convey the expectation for when the text is used. | ||||
Summary | false | ||||
ExplanationOfBenefit.processNote.text | |||||
Element Id | ExplanationOfBenefit.processNote.text | ||||
Definition | The explanation or description associated with the processing. | ||||
Short Display | Note explanatory text | ||||
Cardinality | 0..1 | ||||
Type | string | ||||
Requirements | Required to provide human readable explanation. | ||||
Summary | false | ||||
ExplanationOfBenefit.processNote.language | |||||
Element Id | ExplanationOfBenefit.processNote.language | ||||
Definition | A code to define the language used in the text of the note. | ||||
Short Display | Language of the text | ||||
Cardinality | 0..1 | ||||
Terminology Binding | All Languages (Required)
| ||||
Type | CodeableConcept | ||||
Requirements | Note text may vary from the resource defined language. | ||||
Summary | false | ||||
Comments | Only required if the language is different from the resource language. | ||||
ExplanationOfBenefit.benefitPeriod | |||||
Element Id | ExplanationOfBenefit.benefitPeriod | ||||
Definition | The term of the benefits documented in this response. | ||||
Short Display | When the benefits are applicable | ||||
Cardinality | 0..1 | ||||
Type | Period | ||||
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. | ||||
Summary | false | ||||
Comments | Not applicable when use=claim. | ||||
ExplanationOfBenefit.benefitBalance | |||||
Element Id | ExplanationOfBenefit.benefitBalance | ||||
Definition | Balance by Benefit Category. | ||||
Short Display | Balance by Benefit Category | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.category | |||||
Element Id | ExplanationOfBenefit.benefitBalance.category | ||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short Display | Benefit classification | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Benefit Category Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to convey the category of service or product for which eligibility is sought. | ||||
Summary | false | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
ExplanationOfBenefit.benefitBalance.excluded | |||||
Element Id | ExplanationOfBenefit.benefitBalance.excluded | ||||
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. | ||||
Short Display | Excluded from the plan | ||||
Cardinality | 0..1 | ||||
Type | boolean | ||||
Requirements | Needed to identify items that are specifically excluded from the coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.name | |||||
Element Id | ExplanationOfBenefit.benefitBalance.name | ||||
Definition | A short name or tag for the benefit. | ||||
Short Display | Short name for the benefit | ||||
Cardinality | 0..1 | ||||
Type | string | ||||
Requirements | Required to align with other plan names. | ||||
Summary | false | ||||
Comments | For example: MED01, or DENT2. | ||||
ExplanationOfBenefit.benefitBalance.description | |||||
Element Id | ExplanationOfBenefit.benefitBalance.description | ||||
Definition | A richer description of the benefit or services covered. | ||||
Short Display | Description of the benefit or services covered | ||||
Cardinality | 0..1 | ||||
Type | string | ||||
Requirements | Needed for human readable reference. | ||||
Summary | false | ||||
Comments | For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'. | ||||
ExplanationOfBenefit.benefitBalance.network | |||||
Element Id | ExplanationOfBenefit.benefitBalance.network | ||||
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. | ||||
Short Display | In or out of network | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Network Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed as in or out of network providers are treated differently under the coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.unit | |||||
Element Id | ExplanationOfBenefit.benefitBalance.unit | ||||
Definition | Indicates if the benefits apply to an individual or to the family. | ||||
Short Display | Individual or family | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Unit Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed for the understanding of the benefits. | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.term | |||||
Element Id | ExplanationOfBenefit.benefitBalance.term | ||||
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. | ||||
Short Display | Annual or lifetime | ||||
Cardinality | 0..1 | ||||
Terminology Binding | Benefit Term Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed for the understanding of the benefits. | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.financial | |||||
Element Id | ExplanationOfBenefit.benefitBalance.financial | ||||
Definition | Benefits Used to date. | ||||
Short Display | Benefit Summary | ||||
Cardinality | 0..* | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.financial.type | |||||
Element Id | ExplanationOfBenefit.benefitBalance.financial.type | ||||
Definition | Classification of benefit being provided. | ||||
Short Display | Benefit classification | ||||
Cardinality | 1..1 | ||||
Terminology Binding | Benefit Type Codes (Example) | ||||
Type | CodeableConcept | ||||
Requirements | Needed to convey the nature of the benefit. | ||||
Summary | false | ||||
Comments | For example: deductible, visits, benefit amount. | ||||
ExplanationOfBenefit.benefitBalance.financial.allowed[x] | |||||
Element Id | ExplanationOfBenefit.benefitBalance.financial.allowed[x] | ||||
Definition | The quantity of the benefit which is permitted under the coverage. | ||||
Short Display | Benefits allowed | ||||
Cardinality | 0..1 | ||||
Type | unsignedInt|string|Money | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Needed to convey the benefits offered under the coverage. | ||||
Summary | false | ||||
ExplanationOfBenefit.benefitBalance.financial.used[x] | |||||
Element Id | ExplanationOfBenefit.benefitBalance.financial.used[x] | ||||
Definition | The quantity of the benefit which have been consumed to date. | ||||
Short Display | Benefits used | ||||
Cardinality | 0..1 | ||||
Type | unsignedInt|Money | ||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||
Requirements | Needed to convey the benefits consumed to date. | ||||
Summary | false |