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Financial Management icon Work GroupMaturity Level: 2 Trial UseSecurity 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 icon (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)
Additional BindingsPurpose
Common Languages Starter Set
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