This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Financial Management Work Group | Maturity Level: 2 | Trial Use | Security Category: Patient | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.
This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.
Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. It may also be used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. An EOB will never be created for patient or subscriber information exchange if an error was detected in the Claim.
It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. When the resource was originally being developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource for multiple purposes.
Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if the payee is the provider as that would leak business confidential information.
Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. Only the ClaimResponse contains the appropriate adjudication information for a payor response to a Claim.
The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.
Additional information regarding electronic claims content and usage may be found at:
The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.
When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.
The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.
When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.
The eClaim domain includes a number of related resourcesExplanationOfBenefit | This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization. |
Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
ClaimResponse | A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim. |
CoverageEligibilityRequest | A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required. |
Structure
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | TU | DomainResource | Explanation of Benefit resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |||||
identifier | 0..* | Identifier | Business Identifier for the resource | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: Explanation Of Benefit Status (Required) | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Codes (Extensible) | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: Example Claim SubType Codes (Example) | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (Required) | ||||
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Author of the claim | |||||
insurer | Σ | 0..1 | Reference(Organization) | Party responsible for reimbursement | ||||
provider | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: Process Priority Codes (Example) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (Example) | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (Example) | |||||
related | 0..* | BackboneElement | Prior or corollary claims | |||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: Example Related Claim Relationship Codes (Example) | |||||
reference | 0..1 | Identifier | File or case reference | |||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
event | 0..* | BackboneElement | Event information | |||||
type | 1..1 | CodeableConcept | Specific event Binding: Dates Type Codes (Example) | |||||
when[x] | 1..1 | Occurance date or period | ||||||
whenDateTime | dateTime | |||||||
whenPeriod | Period | |||||||
payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
type | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (Example) | |||||
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
facility | 0..1 | Reference(Location | Organization) | Servicing Facility | |||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: Claim Processing Codes (Required) | ||||
decision | Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: Claim Adjudication Decision Codes (Example) | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
diagnosisRelatedGroup | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (Example) | |||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: Claim Care Team Role Codes (Example) | |||||
specialty | 0..1 | CodeableConcept | Practitioner or provider specialization Binding: Example Provider Qualification Codes (Example) | |||||
supportingInfo | 0..* | BackboneElement | Supporting information | |||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category Codes (Example) | |||||
code | 0..1 | CodeableConcept | Type of information Binding: Exception Codes (Example) | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Any) | |||||||
valueIdentifier | Identifier | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: Missing Tooth Reason Codes (Example) | |||||
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10 Codes (Example) | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (Example) | |||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: Example Diagnosis on Admission Codes (Example) | |||||
procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
type | 0..* | CodeableConcept | Category of Procedure Binding: Example Procedure Type Codes (Example) | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10 Procedure Codes (Example) | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 0..* | BackboneElement | Patient insurance information | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 0..1 | BackboneElement | Details of the event | |||||
date | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (Extensible) | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
item | 0..* | BackboneElement | Product or service provided | |||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: Example Service Place Codes (Example) | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | BackboneElement | Adjudication results | |||||
decision | 0..1 | CodeableConcept | Result of the adjudication Binding: Claim Adjudication Decision Codes (Example) | |||||
reason | 0..* | CodeableConcept | Reason for result of the adjudication Binding: Claim Adjudication Decision Reason Codes (Example) | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
adjudication | 0..* | BackboneElement | Adjudication details | |||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication Value Codes (Example) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Reason Codes (Example) | |||||
amount | 0..1 | Money | Monetary amount | |||||
quantity | 0..1 | Quantity | Non-monitary value | |||||
detail | 0..* | BackboneElement | Additional items | |||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Detail level adjudication results | |||||
adjudication | 0..* | see adjudication | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional items | |||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Subdetail level adjudication results | |||||
adjudication | 0..* | see adjudication | Subdetail level adjudication details | |||||
addItem | 0..* | BackboneElement | Insurer added line items | |||||
itemSequence | 0..* | positiveInt | Item sequence number | |||||
detailSequence | 0..* | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: Example Service Place Codes (Example) | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
detail | 0..* | BackboneElement | Insurer added line items | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem detail level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
subDetail | 0..* | BackboneElement | Insurer added line items | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem subdetail level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
adjudication | 0..* | see adjudication | Header-level adjudication | |||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication Value Codes (Example) | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
type | 0..1 | CodeableConcept | Partial or complete payment Binding: Example Payment Type Codes (Example) | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: Payment Adjustment Reason Codes (Example) | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (Example) | |||||
form | 0..1 | Attachment | Printed reference or actual form | |||||
processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | CodeableConcept | Note purpose Binding: NoteType (Extensible) | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: All Languages (Required)
| |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |||||
category | 1..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: Network Type Codes (Example) | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: Unit Type Codes (Example) | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: Benefit Term Codes (Example) | |||||
financial | 0..* | BackboneElement | Benefit Summary | |||||
type | 1..1 | CodeableConcept | Benefit classification Binding: Benefit Type Codes (Example) | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |
See the Extensions for this resource
UML Diagram (Legend)
XML Template
<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for the resource --></identifier> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <type><!-- 1..1 CodeableConcept Category or discipline --></type> <subType><!-- 0..1 CodeableConcept More granular claim type --></subType> <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination --> <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient> <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod> <created value="[dateTime]"/><!-- 1..1 Response creation date --> <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer> <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider> <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority> <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested> <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve> <related> <!-- 0..* Prior or corollary claims --> <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim> <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship> <reference><!-- 0..1 Identifier File or case reference --></reference> </related> <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription> <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <payee> <!-- 0..1 Recipient of benefits payable --> <type><!-- 0..1 CodeableConcept Category of recipient --></type> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Recipient reference --></party> </payee> <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility> <claim><!-- 0..1 Reference(Claim) Claim reference --></claim> <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse> <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial --> <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference --> <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod> <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup> <careTeam> <!-- 0..* Care Team members --> <sequence value="[positiveInt]"/><!-- 1..1 Order of care team --> <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider> <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner --> <role><!-- 0..1 CodeableConcept Function within the team --></role> <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty> </careTeam> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category> <code><!-- 0..1 CodeableConcept Type of information --></code> <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]> <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)| Identifier Data to be provided --></value[x]> <reason><!-- 0..1 Coding Explanation for the information --></reason> </supportingInfo> <diagnosis> <!-- 0..* Pertinent diagnosis information --> <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier --> <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type> <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission> </diagnosis> <procedure> <!-- 0..* Clinical procedures performed --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier --> <type><!-- 0..* CodeableConcept Category of Procedure --></type> <date value="[dateTime]"/><!-- 0..1 When the procedure was performed --> <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </procedure> <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) --> <insurance> <!-- 0..* Patient insurance information --> <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number --> </insurance> <accident> <!-- 0..1 Details of the event --> <date value="[date]"/><!-- 0..1 When the incident occurred --> <type><!-- 0..1 CodeableConcept The nature of the accident --></type> <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]> </accident> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <item> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members --> <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses --> <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures --> <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome> <!-- 0..1 Adjudication results --> <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision> <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason> <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference --> <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod> </reviewOutcome> <adjudication> <!-- 0..* Adjudication details --> <category><!-- 1..1 CodeableConcept Type of adjudication information --></category> <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason> <amount><!-- 0..1 Money Monetary amount --></amount> <quantity><!-- 0..1 Quantity Non-monitary value --></quantity> </adjudication> <detail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Detail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication> <subDetail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication> </subDetail> </detail> </item> <addItem> <!-- 0..* Insurer added line items --> <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number --> <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number --> <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> <detail> <!-- 0..* Insurer added line items --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem detail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> <subDetail> <!-- 0..* Insurer added line items --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem subdetail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> </subDetail> </detail> </addItem> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication> <total> <!-- 0..* Adjudication totals --> <category><!-- 1..1 CodeableConcept Type of adjudication information --></category> <amount><!-- 1..1 Money Financial total for the category --></amount> </total> <payment> <!-- 0..1 Payment Details --> <type><!-- 0..1 CodeableConcept Partial or complete payment --></type> <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment> <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason> <date value="[date]"/><!-- 0..1 Expected date of payment --> <amount><!-- 0..1 Money Payable amount after adjustment --></amount> <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier> </payment> <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode> <form><!-- 0..1 Attachment Printed reference or actual form --></form> <processNote> <!-- 0..* Note concerning adjudication --> <number value="[positiveInt]"/><!-- 0..1 Note instance identifier --> <type><!-- 0..1 CodeableConcept Note purpose --></type> <text value="[string]"/><!-- 0..1 Note explanatory text --> <language><!-- 0..1 CodeableConcept Language of the text --></language> </processNote> <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod> <benefitBalance> <!-- 0..* Balance by Benefit Category --> <category><!-- 1..1 CodeableConcept Benefit classification --></category> <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan --> <name value="[string]"/><!-- 0..1 Short name for the benefit --> <description value="[string]"/><!-- 0..1 Description of the benefit or services covered --> <network><!-- 0..1 CodeableConcept In or out of network --></network> <unit><!-- 0..1 CodeableConcept Individual or family --></unit> <term><!-- 0..1 CodeableConcept Annual or lifetime --></term> <financial> <!-- 0..* Benefit Summary --> <type><!-- 1..1 CodeableConcept Benefit classification --></type> <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]> <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]> </financial> </benefitBalance> </ExplanationOfBenefit>
JSON Template
{ "resourceType" : "ExplanationOfBenefit", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for the resource "traceNumber" : [{ Identifier }], // Number for tracking "status" : "<code>", // R! active | cancelled | draft | entered-in-error "type" : { CodeableConcept }, // R! Category or discipline "subType" : { CodeableConcept }, // More granular claim type "use" : "<code>", // R! claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // R! The recipient of the products and services "billablePeriod" : { Period }, // Relevant time frame for the claim "created" : "<dateTime>", // R! Response creation date "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim "insurer" : { Reference(Organization) }, // Party responsible for reimbursement "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim "priority" : { CodeableConcept }, // Desired processing urgency "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds "fundsReserve" : { CodeableConcept }, // Funds reserved status "related" : [{ // Prior or corollary claims "claim" : { Reference(Claim) }, // Reference to the related claim "relationship" : { CodeableConcept }, // How the reference claim is related "reference" : { Identifier } // File or case reference }], "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], "payee" : { // Recipient of benefits payable "type" : { CodeableConcept }, // Category of recipient "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Recipient reference }, "referral" : { Reference(ServiceRequest) }, // Treatment Referral "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "facility" : { Reference(Location|Organization) }, // Servicing Facility "claim" : { Reference(Claim) }, // Claim reference "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference "outcome" : "<code>", // R! queued | complete | error | partial "decision" : { CodeableConcept }, // Result of the adjudication "disposition" : "<string>", // Disposition Message "preAuthRef" : ["<string>"], // Preauthorization reference "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code "careTeam" : [{ // Care Team members "sequence" : "<positiveInt>", // R! Order of care team "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R! Practitioner or organization "responsible" : <boolean>, // Indicator of the lead practitioner "role" : { CodeableConcept }, // Function within the team "specialty" : { CodeableConcept } // Practitioner or provider specialization }], "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "category" : { CodeableConcept }, // R! Classification of the supplied information "code" : { CodeableConcept }, // Type of information // timing[x]: When it occurred. One of these 2: "timingDate" : "<date>", "timingPeriod" : { Period }, // value[x]: Data to be provided. One of these 6: "valueBoolean" : <boolean>, "valueString" : "<string>", "valueQuantity" : { Quantity }, "valueAttachment" : { Attachment }, "valueReference" : { Reference(Any) }, "valueIdentifier" : { Identifier }, "reason" : { Coding } // Explanation for the information }], "diagnosis" : [{ // Pertinent diagnosis information "sequence" : "<positiveInt>", // R! Diagnosis instance identifier // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept }, "diagnosisReference" : { Reference(Condition) }, "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis "onAdmission" : { CodeableConcept } // Present on admission }], "procedure" : [{ // Clinical procedures performed "sequence" : "<positiveInt>", // R! Procedure instance identifier "type" : [{ CodeableConcept }], // Category of Procedure "date" : "<dateTime>", // When the procedure was performed // procedure[x]: Specific clinical procedure. One of these 2: "procedureCodeableConcept" : { CodeableConcept }, "procedureReference" : { Reference(Procedure) }, "udi" : [{ Reference(Device) }] // Unique device identifier }], "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.) "insurance" : [{ // Patient insurance information "focal" : <boolean>, // R! Coverage to be used for adjudication "coverage" : { Reference(Coverage) }, // R! Insurance information "preAuthRef" : ["<string>"] // Prior authorization reference number }], "accident" : { // Details of the event "date" : "<date>", // When the incident occurred "type" : { CodeableConcept }, // The nature of the accident // location[x]: Where the event occurred. One of these 2: "locationAddress" : { Address }, "locationReference" : { Reference(Location) } }, "patientPaid" : { Money }, // Paid by the patient "item" : [{ // Product or service provided "sequence" : "<positiveInt>", // R! Item instance identifier "careTeamSequence" : ["<positiveInt>"], // Applicable care team members "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses "procedureSequence" : ["<positiveInt>"], // Applicable procedures "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under // serviced[x]: Date or dates of service or product delivery. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service or where product was supplied. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "bodySite" : [{ // Anatomical location "site" : [{ CodeableReference(BodyStructure) }], // R! Location "subSite" : [{ CodeableConcept }] // Sub-location }], "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { // Adjudication results "decision" : { CodeableConcept }, // Result of the adjudication "reason" : [{ CodeableConcept }], // Reason for result of the adjudication "preAuthRef" : "<string>", // Preauthorization reference "preAuthPeriod" : { Period } // Preauthorization reference effective period }, "adjudication" : [{ // Adjudication details "category" : { CodeableConcept }, // R! Type of adjudication information "reason" : { CodeableConcept }, // Explanation of adjudication outcome "amount" : { Money }, // Monetary amount "quantity" : { Quantity } // Non-monitary value }], "detail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Product or service provided "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Detail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details "subDetail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Product or service provided "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Subdetail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details }] }] }], "addItem" : [{ // Insurer added line items "itemSequence" : ["<positiveInt>"], // Item sequence number "detailSequence" : ["<positiveInt>"], // Detail sequence number "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number "traceNumber" : [{ Identifier }], // Number for tracking "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under // serviced[x]: Date or dates of service or product delivery. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service or where product was supplied. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "bodySite" : [{ // Anatomical location "site" : [{ CodeableReference(BodyStructure) }], // R! Location "subSite" : [{ CodeableConcept }] // Sub-location }], "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication "detail" : [{ // Insurer added line items "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem detail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication "subDetail" : [{ // Insurer added line items "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem subdetail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication }] }] }], "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication "total" : [{ // Adjudication totals "category" : { CodeableConcept }, // R! Type of adjudication information "amount" : { Money } // R! Financial total for the category }], "payment" : { // Payment Details "type" : { CodeableConcept }, // Partial or complete payment "adjustment" : { Money }, // Payment adjustment for non-claim issues "adjustmentReason" : { CodeableConcept }, // Explanation for the variance "date" : "<date>", // Expected date of payment "amount" : { Money }, // Payable amount after adjustment "identifier" : { Identifier } // Business identifier for the payment }, "formCode" : { CodeableConcept }, // Printed form identifier "form" : { Attachment }, // Printed reference or actual form "processNote" : [{ // Note concerning adjudication "number" : "<positiveInt>", // Note instance identifier "type" : { CodeableConcept }, // Note purpose "text" : "<string>", // Note explanatory text "language" : { CodeableConcept } // Language of the text }], "benefitPeriod" : { Period }, // When the benefits are applicable "benefitBalance" : [{ // Balance by Benefit Category "category" : { CodeableConcept }, // R! Benefit classification "excluded" : <boolean>, // Excluded from the plan "name" : "<string>", // Short name for the benefit "description" : "<string>", // Description of the benefit or services covered "network" : { CodeableConcept }, // In or out of network "unit" : { CodeableConcept }, // Individual or family "term" : { CodeableConcept }, // Annual or lifetime "financial" : [{ // Benefit Summary "type" : { CodeableConcept }, // R! Benefit classification // allowed[x]: Benefits allowed. One of these 3: "allowedUnsignedInt" : "<unsignedInt>", "allowedString" : "<string>", "allowedMoney" : { Money }, // used[x]: Benefits used. One of these 2: "usedUnsignedInt" : "<unsignedInt>", "usedMoney" : { Money } }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:ExplanationOfBenefit; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for the resource fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim fhir:created [ dateTime ] ; # 1..1 Response creation date fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency fhir:fundsReserveRequested [ CodeableConcept ] ; # 0..1 For whom to reserve funds fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status fhir:related ( [ # 0..* Prior or corollary claims fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related fhir:reference [ Identifier ] ; # 0..1 File or case reference ] ... ) ; fhir:prescription [ Reference(MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services or products fhir:originalPrescription [ Reference(MedicationRequest) ] ; # 0..1 Original prescription if superceded by fulfiller fhir:event ( [ # 0..* Event information fhir:type [ CodeableConcept ] ; # 1..1 Specific event # when[x] : 1..1 Occurance date or period. One of these 2 fhir:when [ a fhir:dateTime ; dateTime ] fhir:when [ a fhir:Period ; Period ] ] ... ) ; fhir:payee [ # 0..1 Recipient of benefits payable fhir:type [ CodeableConcept ] ; # 0..1 Category of recipient fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference ] ; fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment Referral fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing Facility fhir:claim [ Reference(Claim) ] ; # 0..1 Claim reference fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Claim response reference fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication fhir:disposition [ string ] ; # 0..1 Disposition Message fhir:preAuthRef ( [ string ] ... ) ; # 0..* Preauthorization reference fhir:preAuthRefPeriod ( [ Period ] ... ) ; # 0..* Preauthorization in-effect period fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code fhir:careTeam ( [ # 0..* Care Team members fhir:sequence [ positiveInt ] ; # 1..1 Order of care team fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner fhir:role [ CodeableConcept ] ; # 0..1 Function within the team fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization ] ... ) ; fhir:supportingInfo ( [ # 0..* Supporting information fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information fhir:code [ CodeableConcept ] ; # 0..1 Type of information # timing[x] : 0..1 When it occurred. One of these 2 fhir:timing [ a fhir:date ; date ] fhir:timing [ a fhir:Period ; Period ] # value[x] : 0..1 Data to be provided. One of these 6 fhir:value [ a fhir:boolean ; boolean ] fhir:value [ a fhir:string ; string ] fhir:value [ a fhir:Quantity ; Quantity ] fhir:value [ a fhir:Attachment ; Attachment ] fhir:value [ a fhir:Reference ; Reference(Any) ] fhir:value [ a fhir:Identifier ; Identifier ] fhir:reason [ Coding ] ; # 0..1 Explanation for the information ] ... ) ; fhir:diagnosis ( [ # 0..* Pertinent diagnosis information fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2 fhir:diagnosis [ a fhir:CodeableConcept ; CodeableConcept ] fhir:diagnosis [ a fhir:Reference ; Reference(Condition) ] fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission ] ... ) ; fhir:procedure ( [ # 0..* Clinical procedures performed fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure fhir:date [ dateTime ] ; # 0..1 When the procedure was performed # procedure[x] : 1..1 Specific clinical procedure. One of these 2 fhir:procedure [ a fhir:CodeableConcept ; CodeableConcept ] fhir:procedure [ a fhir:Reference ; Reference(Procedure) ] fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier ] ... ) ; fhir:precedence [ positiveInt ] ; # 0..1 Precedence (primary, secondary, etc.) fhir:insurance ( [ # 0..* Patient insurance information fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information fhir:preAuthRef ( [ string ] ... ) ; # 0..* Prior authorization reference number ] ... ) ; fhir:accident [ # 0..1 Details of the event fhir:date [ date ] ; # 0..1 When the incident occurred fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident # location[x] : 0..1 Where the event occurred. One of these 2 fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] ] ; fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:item ( [ # 0..* Product or service provided fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier fhir:careTeamSequence ( [ positiveInt ] ... ) ; # 0..* Applicable care team members fhir:diagnosisSequence ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses fhir:procedureSequence ( [ positiveInt ] ... ) ; # 0..* Applicable procedures fhir:informationSequence ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:request ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest| VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] # location[x] : 0..1 Place of service or where product was supplied. One of these 3 fhir:location [ a fhir:CodeableConcept ; CodeableConcept ] fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:bodySite ( [ # 0..* Anatomical location fhir:site ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location fhir:subSite ( [ CodeableConcept ] ... ) ; # 0..* Sub-location ] ... ) ; fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ # 0..1 Adjudication results fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication fhir:reason ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period ] ; fhir:adjudication ( [ # 0..* Adjudication details fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome fhir:amount [ Money ] ; # 0..1 Monetary amount fhir:quantity [ Quantity ] ; # 0..1 Non-monitary value ] ... ) ; fhir:detail ( [ # 0..* Additional items fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Detail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Detail level adjudication details fhir:subDetail ( [ # 0..* Additional items fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details ] ... ) ; ] ... ) ; ] ... ) ; fhir:addItem ( [ # 0..* Insurer added line items fhir:itemSequence ( [ positiveInt ] ... ) ; # 0..* Item sequence number fhir:detailSequence ( [ positiveInt ] ... ) ; # 0..* Detail sequence number fhir:subDetailSequence ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:provider ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:request ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest| VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] # location[x] : 0..1 Place of service or where product was supplied. One of these 3 fhir:location [ a fhir:CodeableConcept ; CodeableConcept ] fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:bodySite ( [ # 0..* Anatomical location fhir:site ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location fhir:subSite ( [ CodeableConcept ] ... ) ; # 0..* Sub-location ] ... ) ; fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication fhir:detail ( [ # 0..* Insurer added line items fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem detail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication fhir:subDetail ( [ # 0..* Insurer added line items fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem subdetail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication ] ... ) ; ] ... ) ; ] ... ) ; fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Header-level adjudication fhir:total ( [ # 0..* Adjudication totals fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information fhir:amount [ Money ] ; # 1..1 Financial total for the category ] ... ) ; fhir:payment [ # 0..1 Payment Details fhir:type [ CodeableConcept ] ; # 0..1 Partial or complete payment fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the variance fhir:date [ date ] ; # 0..1 Expected date of payment fhir:amount [ Money ] ; # 0..1 Payable amount after adjustment fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment ] ; fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form fhir:processNote ( [ # 0..* Note concerning adjudication fhir:number [ positiveInt ] ; # 0..1 Note instance identifier fhir:type [ CodeableConcept ] ; # 0..1 Note purpose fhir:text [ string ] ; # 0..1 Note explanatory text fhir:language [ CodeableConcept ] ; # 0..1 Language of the text ] ... ) ; fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable fhir:benefitBalance ( [ # 0..* Balance by Benefit Category fhir:category [ CodeableConcept ] ; # 1..1 Benefit classification fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan fhir:name [ string ] ; # 0..1 Short name for the benefit fhir:description [ string ] ; # 0..1 Description of the benefit or services covered fhir:network [ CodeableConcept ] ; # 0..1 In or out of network fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime fhir:financial ( [ # 0..* Benefit Summary fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification # allowed[x] : 0..1 Benefits allowed. One of these 3 fhir:allowed [ a fhir:unsignedInt ; unsignedInt ] fhir:allowed [ a fhir:string ; string ] fhir:allowed [ a fhir:Money ; Money ] # used[x] : 0..1 Benefits used. One of these 2 fhir:used [ a fhir:unsignedInt ; unsignedInt ] fhir:used [ a fhir:Money ; Money ] ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
ExplanationOfBenefit | |
ExplanationOfBenefit.traceNumber |
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ExplanationOfBenefit.enterer |
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ExplanationOfBenefit.insurer |
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ExplanationOfBenefit.provider |
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ExplanationOfBenefit.event |
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ExplanationOfBenefit.event.type |
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ExplanationOfBenefit.event.when[x] |
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ExplanationOfBenefit.encounter |
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ExplanationOfBenefit.facility |
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ExplanationOfBenefit.outcome |
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ExplanationOfBenefit.decision |
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ExplanationOfBenefit.diagnosisRelatedGroup |
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ExplanationOfBenefit.careTeam.specialty |
|
ExplanationOfBenefit.supportingInfo.value[x] |
|
ExplanationOfBenefit.insurance |
|
ExplanationOfBenefit.patientPaid |
|
ExplanationOfBenefit.item.traceNumber |
|
ExplanationOfBenefit.item.productOrService |
|
ExplanationOfBenefit.item.productOrServiceEnd |
|
ExplanationOfBenefit.item.request |
|
ExplanationOfBenefit.item.patientPaid |
|
ExplanationOfBenefit.item.tax |
|
ExplanationOfBenefit.item.bodySite |
|
ExplanationOfBenefit.item.bodySite.site |
|
ExplanationOfBenefit.item.bodySite.subSite |
|
ExplanationOfBenefit.item.reviewOutcome |
|
ExplanationOfBenefit.item.reviewOutcome.decision |
|
ExplanationOfBenefit.item.reviewOutcome.reason |
|
ExplanationOfBenefit.item.reviewOutcome.preAuthRef |
|
ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod |
|
ExplanationOfBenefit.item.adjudication.quantity |
|
ExplanationOfBenefit.item.detail.traceNumber |
|
ExplanationOfBenefit.item.detail.productOrService |
|
ExplanationOfBenefit.item.detail.productOrServiceEnd |
|
ExplanationOfBenefit.item.detail.patientPaid |
|
ExplanationOfBenefit.item.detail.tax |
|
ExplanationOfBenefit.item.detail.reviewOutcome |
|
ExplanationOfBenefit.item.detail.subDetail.traceNumber |
|
ExplanationOfBenefit.item.detail.subDetail.productOrService |
|
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd |
|
ExplanationOfBenefit.item.detail.subDetail.patientPaid |
|
ExplanationOfBenefit.item.detail.subDetail.tax |
|
ExplanationOfBenefit.item.detail.subDetail.reviewOutcome |
|
ExplanationOfBenefit.addItem.traceNumber |
|
ExplanationOfBenefit.addItem.revenue |
|
ExplanationOfBenefit.addItem.productOrService |
|
ExplanationOfBenefit.addItem.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.request |
|
ExplanationOfBenefit.addItem.patientPaid |
|
ExplanationOfBenefit.addItem.tax |
|
ExplanationOfBenefit.addItem.bodySite |
|
ExplanationOfBenefit.addItem.bodySite.site |
|
ExplanationOfBenefit.addItem.bodySite.subSite |
|
ExplanationOfBenefit.addItem.reviewOutcome |
|
ExplanationOfBenefit.addItem.detail.traceNumber |
|
ExplanationOfBenefit.addItem.detail.revenue |
|
ExplanationOfBenefit.addItem.detail.productOrService |
|
ExplanationOfBenefit.addItem.detail.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.detail.patientPaid |
|
ExplanationOfBenefit.addItem.detail.tax |
|
ExplanationOfBenefit.addItem.detail.reviewOutcome |
|
ExplanationOfBenefit.addItem.detail.subDetail.traceNumber |
|
ExplanationOfBenefit.addItem.detail.subDetail.revenue |
|
ExplanationOfBenefit.addItem.detail.subDetail.productOrService |
|
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid |
|
ExplanationOfBenefit.addItem.detail.subDetail.tax |
|
ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome |
|
ExplanationOfBenefit.processNote.type |
|
ExplanationOfBenefit.processNote.language |
|
ExplanationOfBenefit.careTeam.qualification |
|
ExplanationOfBenefit.diagnosis.packageCode |
|
ExplanationOfBenefit.item.subSite |
|
ExplanationOfBenefit.item.adjudication.value |
|
ExplanationOfBenefit.addItem.subSite |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Structure
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | TU | DomainResource | Explanation of Benefit resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |||||
identifier | 0..* | Identifier | Business Identifier for the resource | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: Explanation Of Benefit Status (Required) | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Codes (Extensible) | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: Example Claim SubType Codes (Example) | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (Required) | ||||
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Author of the claim | |||||
insurer | Σ | 0..1 | Reference(Organization) | Party responsible for reimbursement | ||||
provider | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: Process Priority Codes (Example) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (Example) | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (Example) | |||||
related | 0..* | BackboneElement | Prior or corollary claims | |||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: Example Related Claim Relationship Codes (Example) | |||||
reference | 0..1 | Identifier | File or case reference | |||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
event | 0..* | BackboneElement | Event information | |||||
type | 1..1 | CodeableConcept | Specific event Binding: Dates Type Codes (Example) | |||||
when[x] | 1..1 | Occurance date or period | ||||||
whenDateTime | dateTime | |||||||
whenPeriod | Period | |||||||
payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
type | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (Example) | |||||
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
facility | 0..1 | Reference(Location | Organization) | Servicing Facility | |||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: Claim Processing Codes (Required) | ||||
decision | Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: Claim Adjudication Decision Codes (Example) | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
diagnosisRelatedGroup | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (Example) | |||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: Claim Care Team Role Codes (Example) | |||||
specialty | 0..1 | CodeableConcept | Practitioner or provider specialization Binding: Example Provider Qualification Codes (Example) | |||||
supportingInfo | 0..* | BackboneElement | Supporting information | |||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Information Category Codes (Example) | |||||
code | 0..1 | CodeableConcept | Type of information Binding: Exception Codes (Example) | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Any) | |||||||
valueIdentifier | Identifier | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: Missing Tooth Reason Codes (Example) | |||||
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10 Codes (Example) | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (Example) | |||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: Example Diagnosis on Admission Codes (Example) | |||||
procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
type | 0..* | CodeableConcept | Category of Procedure Binding: Example Procedure Type Codes (Example) | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10 Procedure Codes (Example) | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 0..* | BackboneElement | Patient insurance information | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 0..1 | BackboneElement | Details of the event | |||||
date | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (Extensible) | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
item | 0..* | BackboneElement | Product or service provided | |||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: Example Service Place Codes (Example) | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | BackboneElement | Adjudication results | |||||
decision | 0..1 | CodeableConcept | Result of the adjudication Binding: Claim Adjudication Decision Codes (Example) | |||||
reason | 0..* | CodeableConcept | Reason for result of the adjudication Binding: Claim Adjudication Decision Reason Codes (Example) | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
adjudication | 0..* | BackboneElement | Adjudication details | |||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication Value Codes (Example) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Reason Codes (Example) | |||||
amount | 0..1 | Money | Monetary amount | |||||
quantity | 0..1 | Quantity | Non-monitary value | |||||
detail | 0..* | BackboneElement | Additional items | |||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Detail level adjudication results | |||||
adjudication | 0..* | see adjudication | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional items | |||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Subdetail level adjudication results | |||||
adjudication | 0..* | see adjudication | Subdetail level adjudication details | |||||
addItem | 0..* | BackboneElement | Insurer added line items | |||||
itemSequence | 0..* | positiveInt | Item sequence number | |||||
detailSequence | 0..* | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: Example Service Place Codes (Example) | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
detail | 0..* | BackboneElement | Insurer added line items | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem detail level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
subDetail | 0..* | BackboneElement | Insurer added line items | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |||||
patientPaid | 0..1 | Money | Paid by the patient | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | see reviewOutcome | Additem subdetail level adjudication results | |||||
adjudication | 0..* | see adjudication | Added items adjudication | |||||
adjudication | 0..* | see adjudication | Header-level adjudication | |||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication Value Codes (Example) | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
type | 0..1 | CodeableConcept | Partial or complete payment Binding: Example Payment Type Codes (Example) | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: Payment Adjustment Reason Codes (Example) | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (Example) | |||||
form | 0..1 | Attachment | Printed reference or actual form | |||||
processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | CodeableConcept | Note purpose Binding: NoteType (Extensible) | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: All Languages (Required)
| |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |||||
category | 1..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: Network Type Codes (Example) | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: Unit Type Codes (Example) | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: Benefit Term Codes (Example) | |||||
financial | 0..* | BackboneElement | Benefit Summary | |||||
type | 1..1 | CodeableConcept | Benefit classification Binding: Benefit Type Codes (Example) | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |
See the Extensions for this resource
XML Template
<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for the resource --></identifier> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <type><!-- 1..1 CodeableConcept Category or discipline --></type> <subType><!-- 0..1 CodeableConcept More granular claim type --></subType> <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination --> <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient> <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod> <created value="[dateTime]"/><!-- 1..1 Response creation date --> <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer> <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider> <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority> <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested> <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve> <related> <!-- 0..* Prior or corollary claims --> <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim> <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship> <reference><!-- 0..1 Identifier File or case reference --></reference> </related> <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription> <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <payee> <!-- 0..1 Recipient of benefits payable --> <type><!-- 0..1 CodeableConcept Category of recipient --></type> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Recipient reference --></party> </payee> <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility> <claim><!-- 0..1 Reference(Claim) Claim reference --></claim> <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse> <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial --> <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference --> <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod> <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup> <careTeam> <!-- 0..* Care Team members --> <sequence value="[positiveInt]"/><!-- 1..1 Order of care team --> <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider> <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner --> <role><!-- 0..1 CodeableConcept Function within the team --></role> <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty> </careTeam> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category> <code><!-- 0..1 CodeableConcept Type of information --></code> <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]> <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)| Identifier Data to be provided --></value[x]> <reason><!-- 0..1 Coding Explanation for the information --></reason> </supportingInfo> <diagnosis> <!-- 0..* Pertinent diagnosis information --> <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier --> <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type> <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission> </diagnosis> <procedure> <!-- 0..* Clinical procedures performed --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier --> <type><!-- 0..* CodeableConcept Category of Procedure --></type> <date value="[dateTime]"/><!-- 0..1 When the procedure was performed --> <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </procedure> <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) --> <insurance> <!-- 0..* Patient insurance information --> <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number --> </insurance> <accident> <!-- 0..1 Details of the event --> <date value="[date]"/><!-- 0..1 When the incident occurred --> <type><!-- 0..1 CodeableConcept The nature of the accident --></type> <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]> </accident> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <item> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members --> <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses --> <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures --> <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome> <!-- 0..1 Adjudication results --> <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision> <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason> <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference --> <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod> </reviewOutcome> <adjudication> <!-- 0..* Adjudication details --> <category><!-- 1..1 CodeableConcept Type of adjudication information --></category> <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason> <amount><!-- 0..1 Money Monetary amount --></amount> <quantity><!-- 0..1 Quantity Non-monitary value --></quantity> </adjudication> <detail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Detail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication> <subDetail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication> </subDetail> </detail> </item> <addItem> <!-- 0..* Insurer added line items --> <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number --> <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number --> <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> <detail> <!-- 0..* Insurer added line items --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem detail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> <subDetail> <!-- 0..* Insurer added line items --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers --> <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem subdetail level adjudication results --></reviewOutcome> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> </subDetail> </detail> </addItem> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication> <total> <!-- 0..* Adjudication totals --> <category><!-- 1..1 CodeableConcept Type of adjudication information --></category> <amount><!-- 1..1 Money Financial total for the category --></amount> </total> <payment> <!-- 0..1 Payment Details --> <type><!-- 0..1 CodeableConcept Partial or complete payment --></type> <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment> <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason> <date value="[date]"/><!-- 0..1 Expected date of payment --> <amount><!-- 0..1 Money Payable amount after adjustment --></amount> <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier> </payment> <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode> <form><!-- 0..1 Attachment Printed reference or actual form --></form> <processNote> <!-- 0..* Note concerning adjudication --> <number value="[positiveInt]"/><!-- 0..1 Note instance identifier --> <type><!-- 0..1 CodeableConcept Note purpose --></type> <text value="[string]"/><!-- 0..1 Note explanatory text --> <language><!-- 0..1 CodeableConcept Language of the text --></language> </processNote> <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod> <benefitBalance> <!-- 0..* Balance by Benefit Category --> <category><!-- 1..1 CodeableConcept Benefit classification --></category> <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan --> <name value="[string]"/><!-- 0..1 Short name for the benefit --> <description value="[string]"/><!-- 0..1 Description of the benefit or services covered --> <network><!-- 0..1 CodeableConcept In or out of network --></network> <unit><!-- 0..1 CodeableConcept Individual or family --></unit> <term><!-- 0..1 CodeableConcept Annual or lifetime --></term> <financial> <!-- 0..* Benefit Summary --> <type><!-- 1..1 CodeableConcept Benefit classification --></type> <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]> <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]> </financial> </benefitBalance> </ExplanationOfBenefit>
JSON Template
{ "resourceType" : "ExplanationOfBenefit", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for the resource "traceNumber" : [{ Identifier }], // Number for tracking "status" : "<code>", // R! active | cancelled | draft | entered-in-error "type" : { CodeableConcept }, // R! Category or discipline "subType" : { CodeableConcept }, // More granular claim type "use" : "<code>", // R! claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // R! The recipient of the products and services "billablePeriod" : { Period }, // Relevant time frame for the claim "created" : "<dateTime>", // R! Response creation date "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim "insurer" : { Reference(Organization) }, // Party responsible for reimbursement "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim "priority" : { CodeableConcept }, // Desired processing urgency "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds "fundsReserve" : { CodeableConcept }, // Funds reserved status "related" : [{ // Prior or corollary claims "claim" : { Reference(Claim) }, // Reference to the related claim "relationship" : { CodeableConcept }, // How the reference claim is related "reference" : { Identifier } // File or case reference }], "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], "payee" : { // Recipient of benefits payable "type" : { CodeableConcept }, // Category of recipient "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Recipient reference }, "referral" : { Reference(ServiceRequest) }, // Treatment Referral "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "facility" : { Reference(Location|Organization) }, // Servicing Facility "claim" : { Reference(Claim) }, // Claim reference "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference "outcome" : "<code>", // R! queued | complete | error | partial "decision" : { CodeableConcept }, // Result of the adjudication "disposition" : "<string>", // Disposition Message "preAuthRef" : ["<string>"], // Preauthorization reference "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code "careTeam" : [{ // Care Team members "sequence" : "<positiveInt>", // R! Order of care team "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R! Practitioner or organization "responsible" : <boolean>, // Indicator of the lead practitioner "role" : { CodeableConcept }, // Function within the team "specialty" : { CodeableConcept } // Practitioner or provider specialization }], "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "category" : { CodeableConcept }, // R! Classification of the supplied information "code" : { CodeableConcept }, // Type of information // timing[x]: When it occurred. One of these 2: "timingDate" : "<date>", "timingPeriod" : { Period }, // value[x]: Data to be provided. One of these 6: "valueBoolean" : <boolean>, "valueString" : "<string>", "valueQuantity" : { Quantity }, "valueAttachment" : { Attachment }, "valueReference" : { Reference(Any) }, "valueIdentifier" : { Identifier }, "reason" : { Coding } // Explanation for the information }], "diagnosis" : [{ // Pertinent diagnosis information "sequence" : "<positiveInt>", // R! Diagnosis instance identifier // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept }, "diagnosisReference" : { Reference(Condition) }, "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis "onAdmission" : { CodeableConcept } // Present on admission }], "procedure" : [{ // Clinical procedures performed "sequence" : "<positiveInt>", // R! Procedure instance identifier "type" : [{ CodeableConcept }], // Category of Procedure "date" : "<dateTime>", // When the procedure was performed // procedure[x]: Specific clinical procedure. One of these 2: "procedureCodeableConcept" : { CodeableConcept }, "procedureReference" : { Reference(Procedure) }, "udi" : [{ Reference(Device) }] // Unique device identifier }], "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.) "insurance" : [{ // Patient insurance information "focal" : <boolean>, // R! Coverage to be used for adjudication "coverage" : { Reference(Coverage) }, // R! Insurance information "preAuthRef" : ["<string>"] // Prior authorization reference number }], "accident" : { // Details of the event "date" : "<date>", // When the incident occurred "type" : { CodeableConcept }, // The nature of the accident // location[x]: Where the event occurred. One of these 2: "locationAddress" : { Address }, "locationReference" : { Reference(Location) } }, "patientPaid" : { Money }, // Paid by the patient "item" : [{ // Product or service provided "sequence" : "<positiveInt>", // R! Item instance identifier "careTeamSequence" : ["<positiveInt>"], // Applicable care team members "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses "procedureSequence" : ["<positiveInt>"], // Applicable procedures "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under // serviced[x]: Date or dates of service or product delivery. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service or where product was supplied. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "bodySite" : [{ // Anatomical location "site" : [{ CodeableReference(BodyStructure) }], // R! Location "subSite" : [{ CodeableConcept }] // Sub-location }], "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { // Adjudication results "decision" : { CodeableConcept }, // Result of the adjudication "reason" : [{ CodeableConcept }], // Reason for result of the adjudication "preAuthRef" : "<string>", // Preauthorization reference "preAuthPeriod" : { Period } // Preauthorization reference effective period }, "adjudication" : [{ // Adjudication details "category" : { CodeableConcept }, // R! Type of adjudication information "reason" : { CodeableConcept }, // Explanation of adjudication outcome "amount" : { Money }, // Monetary amount "quantity" : { Quantity } // Non-monitary value }], "detail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Product or service provided "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Detail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details "subDetail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Product or service provided "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Subdetail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details }] }] }], "addItem" : [{ // Insurer added line items "itemSequence" : ["<positiveInt>"], // Item sequence number "detailSequence" : ["<positiveInt>"], // Detail sequence number "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number "traceNumber" : [{ Identifier }], // Number for tracking "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under // serviced[x]: Date or dates of service or product delivery. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service or where product was supplied. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "bodySite" : [{ // Anatomical location "site" : [{ CodeableReference(BodyStructure) }], // R! Location "subSite" : [{ CodeableConcept }] // Sub-location }], "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication "detail" : [{ // Insurer added line items "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem detail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication "subDetail" : [{ // Insurer added line items "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // Applicable note numbers "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem subdetail level adjudication results "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication }] }] }], "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication "total" : [{ // Adjudication totals "category" : { CodeableConcept }, // R! Type of adjudication information "amount" : { Money } // R! Financial total for the category }], "payment" : { // Payment Details "type" : { CodeableConcept }, // Partial or complete payment "adjustment" : { Money }, // Payment adjustment for non-claim issues "adjustmentReason" : { CodeableConcept }, // Explanation for the variance "date" : "<date>", // Expected date of payment "amount" : { Money }, // Payable amount after adjustment "identifier" : { Identifier } // Business identifier for the payment }, "formCode" : { CodeableConcept }, // Printed form identifier "form" : { Attachment }, // Printed reference or actual form "processNote" : [{ // Note concerning adjudication "number" : "<positiveInt>", // Note instance identifier "type" : { CodeableConcept }, // Note purpose "text" : "<string>", // Note explanatory text "language" : { CodeableConcept } // Language of the text }], "benefitPeriod" : { Period }, // When the benefits are applicable "benefitBalance" : [{ // Balance by Benefit Category "category" : { CodeableConcept }, // R! Benefit classification "excluded" : <boolean>, // Excluded from the plan "name" : "<string>", // Short name for the benefit "description" : "<string>", // Description of the benefit or services covered "network" : { CodeableConcept }, // In or out of network "unit" : { CodeableConcept }, // Individual or family "term" : { CodeableConcept }, // Annual or lifetime "financial" : [{ // Benefit Summary "type" : { CodeableConcept }, // R! Benefit classification // allowed[x]: Benefits allowed. One of these 3: "allowedUnsignedInt" : "<unsignedInt>", "allowedString" : "<string>", "allowedMoney" : { Money }, // used[x]: Benefits used. One of these 2: "usedUnsignedInt" : "<unsignedInt>", "usedMoney" : { Money } }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:ExplanationOfBenefit; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for the resource fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim fhir:created [ dateTime ] ; # 1..1 Response creation date fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency fhir:fundsReserveRequested [ CodeableConcept ] ; # 0..1 For whom to reserve funds fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status fhir:related ( [ # 0..* Prior or corollary claims fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related fhir:reference [ Identifier ] ; # 0..1 File or case reference ] ... ) ; fhir:prescription [ Reference(MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services or products fhir:originalPrescription [ Reference(MedicationRequest) ] ; # 0..1 Original prescription if superceded by fulfiller fhir:event ( [ # 0..* Event information fhir:type [ CodeableConcept ] ; # 1..1 Specific event # when[x] : 1..1 Occurance date or period. One of these 2 fhir:when [ a fhir:dateTime ; dateTime ] fhir:when [ a fhir:Period ; Period ] ] ... ) ; fhir:payee [ # 0..1 Recipient of benefits payable fhir:type [ CodeableConcept ] ; # 0..1 Category of recipient fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference ] ; fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment Referral fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing Facility fhir:claim [ Reference(Claim) ] ; # 0..1 Claim reference fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Claim response reference fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication fhir:disposition [ string ] ; # 0..1 Disposition Message fhir:preAuthRef ( [ string ] ... ) ; # 0..* Preauthorization reference fhir:preAuthRefPeriod ( [ Period ] ... ) ; # 0..* Preauthorization in-effect period fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code fhir:careTeam ( [ # 0..* Care Team members fhir:sequence [ positiveInt ] ; # 1..1 Order of care team fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner fhir:role [ CodeableConcept ] ; # 0..1 Function within the team fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization ] ... ) ; fhir:supportingInfo ( [ # 0..* Supporting information fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information fhir:code [ CodeableConcept ] ; # 0..1 Type of information # timing[x] : 0..1 When it occurred. One of these 2 fhir:timing [ a fhir:date ; date ] fhir:timing [ a fhir:Period ; Period ] # value[x] : 0..1 Data to be provided. One of these 6 fhir:value [ a fhir:boolean ; boolean ] fhir:value [ a fhir:string ; string ] fhir:value [ a fhir:Quantity ; Quantity ] fhir:value [ a fhir:Attachment ; Attachment ] fhir:value [ a fhir:Reference ; Reference(Any) ] fhir:value [ a fhir:Identifier ; Identifier ] fhir:reason [ Coding ] ; # 0..1 Explanation for the information ] ... ) ; fhir:diagnosis ( [ # 0..* Pertinent diagnosis information fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2 fhir:diagnosis [ a fhir:CodeableConcept ; CodeableConcept ] fhir:diagnosis [ a fhir:Reference ; Reference(Condition) ] fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission ] ... ) ; fhir:procedure ( [ # 0..* Clinical procedures performed fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure fhir:date [ dateTime ] ; # 0..1 When the procedure was performed # procedure[x] : 1..1 Specific clinical procedure. One of these 2 fhir:procedure [ a fhir:CodeableConcept ; CodeableConcept ] fhir:procedure [ a fhir:Reference ; Reference(Procedure) ] fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier ] ... ) ; fhir:precedence [ positiveInt ] ; # 0..1 Precedence (primary, secondary, etc.) fhir:insurance ( [ # 0..* Patient insurance information fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information fhir:preAuthRef ( [ string ] ... ) ; # 0..* Prior authorization reference number ] ... ) ; fhir:accident [ # 0..1 Details of the event fhir:date [ date ] ; # 0..1 When the incident occurred fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident # location[x] : 0..1 Where the event occurred. One of these 2 fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] ] ; fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:item ( [ # 0..* Product or service provided fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier fhir:careTeamSequence ( [ positiveInt ] ... ) ; # 0..* Applicable care team members fhir:diagnosisSequence ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses fhir:procedureSequence ( [ positiveInt ] ... ) ; # 0..* Applicable procedures fhir:informationSequence ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:request ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest| VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] # location[x] : 0..1 Place of service or where product was supplied. One of these 3 fhir:location [ a fhir:CodeableConcept ; CodeableConcept ] fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:bodySite ( [ # 0..* Anatomical location fhir:site ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location fhir:subSite ( [ CodeableConcept ] ... ) ; # 0..* Sub-location ] ... ) ; fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ # 0..1 Adjudication results fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication fhir:reason ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period ] ; fhir:adjudication ( [ # 0..* Adjudication details fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome fhir:amount [ Money ] ; # 0..1 Monetary amount fhir:quantity [ Quantity ] ; # 0..1 Non-monitary value ] ... ) ; fhir:detail ( [ # 0..* Additional items fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Detail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Detail level adjudication details fhir:subDetail ( [ # 0..* Additional items fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details ] ... ) ; ] ... ) ; ] ... ) ; fhir:addItem ( [ # 0..* Insurer added line items fhir:itemSequence ( [ positiveInt ] ... ) ; # 0..* Item sequence number fhir:detailSequence ( [ positiveInt ] ... ) ; # 0..* Detail sequence number fhir:subDetailSequence ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:provider ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:request ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest| VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] # location[x] : 0..1 Place of service or where product was supplied. One of these 3 fhir:location [ a fhir:CodeableConcept ; CodeableConcept ] fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:bodySite ( [ # 0..* Anatomical location fhir:site ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location fhir:subSite ( [ CodeableConcept ] ... ) ; # 0..* Sub-location ] ... ) ; fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication fhir:detail ( [ # 0..* Insurer added line items fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem detail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication fhir:subDetail ( [ # 0..* Insurer added line items fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:noteNumber ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem subdetail level adjudication results fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication ] ... ) ; ] ... ) ; ] ... ) ; fhir:adjudication ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Header-level adjudication fhir:total ( [ # 0..* Adjudication totals fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information fhir:amount [ Money ] ; # 1..1 Financial total for the category ] ... ) ; fhir:payment [ # 0..1 Payment Details fhir:type [ CodeableConcept ] ; # 0..1 Partial or complete payment fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the variance fhir:date [ date ] ; # 0..1 Expected date of payment fhir:amount [ Money ] ; # 0..1 Payable amount after adjustment fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment ] ; fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form fhir:processNote ( [ # 0..* Note concerning adjudication fhir:number [ positiveInt ] ; # 0..1 Note instance identifier fhir:type [ CodeableConcept ] ; # 0..1 Note purpose fhir:text [ string ] ; # 0..1 Note explanatory text fhir:language [ CodeableConcept ] ; # 0..1 Language of the text ] ... ) ; fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable fhir:benefitBalance ( [ # 0..* Balance by Benefit Category fhir:category [ CodeableConcept ] ; # 1..1 Benefit classification fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan fhir:name [ string ] ; # 0..1 Short name for the benefit fhir:description [ string ] ; # 0..1 Description of the benefit or services covered fhir:network [ CodeableConcept ] ; # 0..1 In or out of network fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime fhir:financial ( [ # 0..* Benefit Summary fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification # allowed[x] : 0..1 Benefits allowed. One of these 3 fhir:allowed [ a fhir:unsignedInt ; unsignedInt ] fhir:allowed [ a fhir:string ; string ] fhir:allowed [ a fhir:Money ; Money ] # used[x] : 0..1 Benefits used. One of these 2 fhir:used [ a fhir:unsignedInt ; unsignedInt ] fhir:used [ a fhir:Money ; Money ] ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
ExplanationOfBenefit | |
ExplanationOfBenefit.traceNumber |
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ExplanationOfBenefit.enterer |
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ExplanationOfBenefit.insurer |
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ExplanationOfBenefit.provider |
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ExplanationOfBenefit.event |
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ExplanationOfBenefit.event.type |
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ExplanationOfBenefit.event.when[x] |
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ExplanationOfBenefit.encounter |
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ExplanationOfBenefit.facility |
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ExplanationOfBenefit.outcome |
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ExplanationOfBenefit.decision |
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ExplanationOfBenefit.diagnosisRelatedGroup |
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ExplanationOfBenefit.careTeam.specialty |
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ExplanationOfBenefit.supportingInfo.value[x] |
|
ExplanationOfBenefit.insurance |
|
ExplanationOfBenefit.patientPaid |
|
ExplanationOfBenefit.item.traceNumber |
|
ExplanationOfBenefit.item.productOrService |
|
ExplanationOfBenefit.item.productOrServiceEnd |
|
ExplanationOfBenefit.item.request |
|
ExplanationOfBenefit.item.patientPaid |
|
ExplanationOfBenefit.item.tax |
|
ExplanationOfBenefit.item.bodySite |
|
ExplanationOfBenefit.item.bodySite.site |
|
ExplanationOfBenefit.item.bodySite.subSite |
|
ExplanationOfBenefit.item.reviewOutcome |
|
ExplanationOfBenefit.item.reviewOutcome.decision |
|
ExplanationOfBenefit.item.reviewOutcome.reason |
|
ExplanationOfBenefit.item.reviewOutcome.preAuthRef |
|
ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod |
|
ExplanationOfBenefit.item.adjudication.quantity |
|
ExplanationOfBenefit.item.detail.traceNumber |
|
ExplanationOfBenefit.item.detail.productOrService |
|
ExplanationOfBenefit.item.detail.productOrServiceEnd |
|
ExplanationOfBenefit.item.detail.patientPaid |
|
ExplanationOfBenefit.item.detail.tax |
|
ExplanationOfBenefit.item.detail.reviewOutcome |
|
ExplanationOfBenefit.item.detail.subDetail.traceNumber |
|
ExplanationOfBenefit.item.detail.subDetail.productOrService |
|
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd |
|
ExplanationOfBenefit.item.detail.subDetail.patientPaid |
|
ExplanationOfBenefit.item.detail.subDetail.tax |
|
ExplanationOfBenefit.item.detail.subDetail.reviewOutcome |
|
ExplanationOfBenefit.addItem.traceNumber |
|
ExplanationOfBenefit.addItem.revenue |
|
ExplanationOfBenefit.addItem.productOrService |
|
ExplanationOfBenefit.addItem.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.request |
|
ExplanationOfBenefit.addItem.patientPaid |
|
ExplanationOfBenefit.addItem.tax |
|
ExplanationOfBenefit.addItem.bodySite |
|
ExplanationOfBenefit.addItem.bodySite.site |
|
ExplanationOfBenefit.addItem.bodySite.subSite |
|
ExplanationOfBenefit.addItem.reviewOutcome |
|
ExplanationOfBenefit.addItem.detail.traceNumber |
|
ExplanationOfBenefit.addItem.detail.revenue |
|
ExplanationOfBenefit.addItem.detail.productOrService |
|
ExplanationOfBenefit.addItem.detail.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.detail.patientPaid |
|
ExplanationOfBenefit.addItem.detail.tax |
|
ExplanationOfBenefit.addItem.detail.reviewOutcome |
|
ExplanationOfBenefit.addItem.detail.subDetail.traceNumber |
|
ExplanationOfBenefit.addItem.detail.subDetail.revenue |
|
ExplanationOfBenefit.addItem.detail.subDetail.productOrService |
|
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd |
|
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid |
|
ExplanationOfBenefit.addItem.detail.subDetail.tax |
|
ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome |
|
ExplanationOfBenefit.processNote.type |
|
ExplanationOfBenefit.processNote.language |
|
ExplanationOfBenefit.careTeam.qualification |
|
ExplanationOfBenefit.diagnosis.packageCode |
|
ExplanationOfBenefit.item.subSite |
|
ExplanationOfBenefit.item.adjudication.value |
|
ExplanationOfBenefit.addItem.subSite |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis
Path | ValueSet | Type | Documentation |
---|---|---|---|
ExplanationOfBenefit.status | ExplanationOfBenefitStatus | Required | A code specifying the state of the resource instance. |
ExplanationOfBenefit.type | ClaimTypeCodes | Extensible | This value set includes Claim Type codes. |
ExplanationOfBenefit.subType | ExampleClaimSubTypeCodes | Example | This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation. |
ExplanationOfBenefit.use | Use | Required | The purpose of the Claim: predetermination, preauthorization, claim. |
ExplanationOfBenefit.priority | ProcessPriorityCodes | Example | This value set includes the financial processing priority codes. |
ExplanationOfBenefit.fundsReserveRequested | FundsReservationCodes | Example | This value set includes sample funds reservation type codes. |
ExplanationOfBenefit.fundsReserve | FundsReservationCodes | Example | This value set includes sample funds reservation type codes. |
ExplanationOfBenefit.related.relationship | ExampleRelatedClaimRelationshipCodes | Example | This value set includes sample Related Claim Relationship codes. |
ExplanationOfBenefit.event.type | DatesTypeCodes (a valid code from Dates Event Type Codes) | Example | This value set includes sample Dates Type codes. |
ExplanationOfBenefit.payee.type | ClaimPayeeTypeCodes (a valid code from Payee Type Codes ) | Example | This value set includes sample Payee Type codes. |
ExplanationOfBenefit.outcome | ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes) | Required | This value set includes Claim Processing Outcome codes. |
ExplanationOfBenefit.decision | ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) | Example | This value set includes Claim Adjudication Decision codes. |
ExplanationOfBenefit.diagnosisRelatedGroup | ExampleDiagnosisRelatedGroupCodes | Example | This value set includes example Diagnosis Related Group codes. |
ExplanationOfBenefit.careTeam.role | ClaimCareTeamRoleCodes | Example | This value set includes sample Claim Care Team Role codes. |
ExplanationOfBenefit.careTeam.specialty | ExampleProviderQualificationCodes | Example | This value set includes sample Provider Qualification codes. |
ExplanationOfBenefit.supportingInfo.category | ClaimInformationCategoryCodes | Example | This value set includes sample Information Category codes. |
ExplanationOfBenefit.supportingInfo.code | ExceptionCodes | Example | This value set includes sample Exception codes. |
ExplanationOfBenefit.supportingInfo.reason | MissingToothReasonCodes | Example | This value set includes sample Missing Tooth Reason codes. |
ExplanationOfBenefit.diagnosis.diagnosis[x] | ICD10Codes (a valid code from ICD-10 ) | Example | This value set includes sample ICD-10 codes. |
ExplanationOfBenefit.diagnosis.type | ExampleDiagnosisTypeCodes | Example | This value set includes example Diagnosis Type codes. |
ExplanationOfBenefit.diagnosis.onAdmission | ExampleDiagnosisOnAdmissionCodes | Example | This value set includes example Diagnosis on Admission codes. |
ExplanationOfBenefit.procedure.type | ExampleProcedureTypeCodes | Example | This value set includes example Procedure Type codes. |
ExplanationOfBenefit.procedure.procedure[x] | ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes) | Example | This value set includes sample ICD-10 Procedure codes. |
ExplanationOfBenefit.accident.type | ActIncidentCode | Extensible | Set of codes indicating the type of incident or accident. |
ExplanationOfBenefit.item.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.item.category | BenefitCategoryCodes | Example | This value set includes examples of Benefit Category codes. |
ExplanationOfBenefit.item.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.item.programCode | ExampleProgramReasonCodes | Example | This value set includes sample Program Reason Span codes. |
ExplanationOfBenefit.item.location[x] | ExampleServicePlaceCodes | Example | This value set includes a smattering of Service Place codes. |
ExplanationOfBenefit.item.bodySite.site | OralSiteCodes | Example | This value set includes a smattering of FDI oral site codes. |
ExplanationOfBenefit.item.bodySite.subSite | SurfaceCodes | Example | This value set includes a smattering of FDI tooth surface codes. |
ExplanationOfBenefit.item.reviewOutcome.decision | ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) | Example | This value set includes Claim Adjudication Decision codes. |
ExplanationOfBenefit.item.reviewOutcome.reason | ClaimAdjudicationDecisionReasonCodes | Example | This value set includes example Claim Adjudication Decision Reason codes. |
ExplanationOfBenefit.item.adjudication.category | AdjudicationValueCodes | Example | This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc. |
ExplanationOfBenefit.item.adjudication.reason | AdjudicationReasonCodes | Example | This value set includes smattering of Adjudication Reason codes. |
ExplanationOfBenefit.item.detail.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.item.detail.category | BenefitCategoryCodes | Example | This value set includes examples of Benefit Category codes. |
ExplanationOfBenefit.item.detail.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.detail.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.detail.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.item.detail.programCode | ExampleProgramReasonCodes | Example | This value set includes sample Program Reason Span codes. |
ExplanationOfBenefit.item.detail.subDetail.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.item.detail.subDetail.category | BenefitCategoryCodes | Example | This value set includes examples of Benefit Category codes. |
ExplanationOfBenefit.item.detail.subDetail.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.item.detail.subDetail.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.item.detail.subDetail.programCode | ExampleProgramReasonCodes | Example | This value set includes sample Program Reason Span codes. |
ExplanationOfBenefit.addItem.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.addItem.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.addItem.programCode | ExampleProgramReasonCodes | Example | This value set includes sample Program Reason Span codes. |
ExplanationOfBenefit.addItem.location[x] | ExampleServicePlaceCodes | Example | This value set includes a smattering of Service Place codes. |
ExplanationOfBenefit.addItem.bodySite.site | OralSiteCodes | Example | This value set includes a smattering of FDI oral site codes. |
ExplanationOfBenefit.addItem.bodySite.subSite | SurfaceCodes | Example | This value set includes a smattering of FDI tooth surface codes. |
ExplanationOfBenefit.addItem.detail.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.addItem.detail.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.detail.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.detail.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.addItem.detail.subDetail.revenue | ExampleRevenueCenterCodes | Example | This value set includes sample Revenue Center codes. |
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
ExplanationOfBenefit.addItem.detail.subDetail.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
ExplanationOfBenefit.total.category | AdjudicationValueCodes | Example | This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc. |
ExplanationOfBenefit.payment.type | ExamplePaymentTypeCodes | Example | This value set includes example Payment Type codes. |
ExplanationOfBenefit.payment.adjustmentReason | PaymentAdjustmentReasonCodes | Example | This value set includes smattering of Payment Adjustment Reason codes. |
ExplanationOfBenefit.formCode | FormCodes | Example | This value set includes a sample set of Forms codes. |
ExplanationOfBenefit.processNote.type | NoteType | Extensible | The presentation types of notes. |
ExplanationOfBenefit.processNote.language | AllLanguages (a valid code from Tags for the Identification of Languages ) | Required | This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47) |
Common Languages | starter | ||
ExplanationOfBenefit.benefitBalance.category | BenefitCategoryCodes | Example | This value set includes examples of Benefit Category codes. |
ExplanationOfBenefit.benefitBalance.network | NetworkTypeCodes | Example | This value set includes a smattering of Network type codes. |
ExplanationOfBenefit.benefitBalance.unit | UnitTypeCodes | Example | This value set includes a smattering of Unit type codes. |
ExplanationOfBenefit.benefitBalance.term | BenefitTermCodes | Example | This value set includes a smattering of Benefit Term codes. |
ExplanationOfBenefit.benefitBalance.financial.type | BenefitTypeCodes | Example | This value set includes a smattering of Benefit type codes. |
The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.
Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an .elementSequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.
The .noteNumber element, which appears at the .item, .detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumbers for each of the appropriate line items or details.
Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
care-team | reference | Member of the CareTeam | ExplanationOfBenefit.careTeam.provider (Practitioner, Organization, PractitionerRole) |
|
claim | reference | The reference to the claim | ExplanationOfBenefit.claim (Claim) |
|
coverage | reference | The plan under which the claim was adjudicated | ExplanationOfBenefit.insurance.coverage (Coverage) |
|
created | date | The creation date for the EOB | ExplanationOfBenefit.created | |
detail-udi | reference | UDI associated with a line item detail product or service | ExplanationOfBenefit.item.detail.udi (Device) |
|
disposition | string | The contents of the disposition message | ExplanationOfBenefit.disposition | |
encounter | reference | Encounters associated with a billed line item | ExplanationOfBenefit.item.encounter (Encounter) |
29 Resources |
enterer | reference | The party responsible for the entry of the Claim | ExplanationOfBenefit.enterer (Practitioner, Patient, PractitionerRole, RelatedPerson) |
|
facility | reference | Facility responsible for the goods and services | ExplanationOfBenefit.facility (Organization, Location) |
|
identifier | token | The business identifier of the Explanation of Benefit | ExplanationOfBenefit.identifier | 65 Resources |
item-udi | reference | UDI associated with a line item product or service | ExplanationOfBenefit.item.udi (Device) |
|
patient | reference | The reference to the patient | ExplanationOfBenefit.patient (Patient) |
65 Resources |
payee | reference | The party receiving any payment for the Claim | ExplanationOfBenefit.payee.party (Practitioner, Organization, Patient, PractitionerRole, RelatedPerson) |
|
procedure-udi | reference | UDI associated with a procedure | ExplanationOfBenefit.procedure.udi (Device) |
|
provider | reference | The reference to the provider | ExplanationOfBenefit.provider (Practitioner, Organization, PractitionerRole) |
|
status | token | Status of the instance | ExplanationOfBenefit.status | |
subdetail-udi | reference | UDI associated with a line item detail subdetail product or service | ExplanationOfBenefit.item.detail.subDetail.udi (Device) |