FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon

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

Detailed Descriptions for the elements in the ExplanationOfBenefit resource.

ExplanationOfBenefit
Element IdExplanationOfBenefit
Definition

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

Short DisplayExplanation of Benefit resource
Cardinality0..*
TypeDomainResource
Alternate NamesEOB
Summaryfalse
ExplanationOfBenefit.identifier
Element IdExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

Short DisplayBusiness Identifier for the resource
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows EOBs to be distinguished and referenced.

Summaryfalse
ExplanationOfBenefit.status
Element IdExplanationOfBenefit.status
Definition

The status of the resource instance.

Short Displayactive | cancelled | draft | entered-in-error
Cardinality1..1
Terminology BindingExplanationOfBenefitStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

ExplanationOfBenefit.type
Element IdExplanationOfBenefit.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Short DisplayCategory or discipline
Cardinality1..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Summarytrue
Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

ExplanationOfBenefit.subType
Element IdExplanationOfBenefit.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Short DisplayMore granular claim type
Cardinality0..1
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Summaryfalse
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

ExplanationOfBenefit.use
Element IdExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.

Short Displayclaim | preauthorization | predetermination
Cardinality1..1
Terminology BindingUse (Required)
Typecode
Requirements

This element is required to understand the nature of the request for adjudication.

Summarytrue
ExplanationOfBenefit.patient
Element IdExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

Short DisplayThe recipient of the products and services
Cardinality1..1
TypeReference(Patient)
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Summarytrue
ExplanationOfBenefit.billablePeriod
Element IdExplanationOfBenefit.billablePeriod
Definition

The period for which charges are being submitted.

Short DisplayRelevant time frame for the claim
Cardinality0..1
TypePeriod
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Summarytrue
Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

ExplanationOfBenefit.created
Element IdExplanationOfBenefit.created
Definition

The date this resource was created.

Short DisplayResponse creation date
Cardinality1..1
TypedateTime
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Summarytrue
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

ExplanationOfBenefit.enterer
Element IdExplanationOfBenefit.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

Short DisplayAuthor of the claim
Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson)
Requirements

Some jurisdictions require the contact information for personnel completing claims.

Summaryfalse
ExplanationOfBenefit.insurer
Element IdExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Short DisplayParty responsible for reimbursement
Cardinality0..1
TypeReference(Organization)
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Summarytrue
ExplanationOfBenefit.provider
Element IdExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

Short DisplayParty responsible for the claim
Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization)
Summarytrue
Comments

This party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

ExplanationOfBenefit.priority
Element IdExplanationOfBenefit.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, normal deferred.

Short DisplayDesired processing urgency
Cardinality0..1
Terminology BindingProcess Priority Codes (Example)
TypeCodeableConcept
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Summaryfalse
Comments

If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.

ExplanationOfBenefit.fundsReserveRequested
Element IdExplanationOfBenefit.fundsReserveRequested
Definition

A code to indicate whether and for whom funds are to be reserved for future claims.

Short DisplayFor whom to reserve funds
Cardinality0..1
Terminology BindingFunds Reservation Codes (Example)
TypeCodeableConcept
Requirements

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Alternate NamesFund pre-allocation
Summaryfalse
Comments

This field is only used for preauthorizations.

ExplanationOfBenefit.fundsReserve
Element IdExplanationOfBenefit.fundsReserve
Definition

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Short DisplayFunds reserved status
Cardinality0..1
Terminology BindingFunds Reservation Codes (Example)
TypeCodeableConcept
Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Summaryfalse
Comments

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

ExplanationOfBenefit.related
Element IdExplanationOfBenefit.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Short DisplayPrior or corollary claims
Cardinality0..*
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Summaryfalse
Comments

For example, for the original treatment and follow-up exams.

ExplanationOfBenefit.related.claim
Element IdExplanationOfBenefit.related.claim
Definition

Reference to a related claim.

Short DisplayReference to the related claim
Cardinality0..1
TypeReference(Claim)
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Summaryfalse
ExplanationOfBenefit.related.relationship
Element IdExplanationOfBenefit.related.relationship
Definition

A code to convey how the claims are related.

Short DisplayHow the reference claim is related
Cardinality0..1
Terminology BindingExample Related Claim Relationship Codes (Example)
TypeCodeableConcept
Requirements

Some insurers need a declaration of the type of relationship.

Summaryfalse
Comments

For example, prior claim or umbrella.

ExplanationOfBenefit.related.reference
Element IdExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Short DisplayFile or case reference
Cardinality0..1
TypeIdentifier
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Summaryfalse
Comments

For example, Property/Casualty insurer claim number or Workers Compensation case number.

ExplanationOfBenefit.prescription
Element IdExplanationOfBenefit.prescription
Definition

Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.

Short DisplayPrescription authorizing services or products
Cardinality0..1
TypeReference(MedicationRequest | VisionPrescription)
Requirements

Required to authorize the dispensing of controlled substances and devices.

Summaryfalse
ExplanationOfBenefit.originalPrescription
Element IdExplanationOfBenefit.originalPrescription
Definition

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Short DisplayOriginal prescription if superceded by fulfiller
Cardinality0..1
TypeReference(MedicationRequest)
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Summaryfalse
Comments

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

ExplanationOfBenefit.payee
Element IdExplanationOfBenefit.payee
Definition

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Short DisplayRecipient of benefits payable
Cardinality0..1
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Summaryfalse
Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

ExplanationOfBenefit.payee.type
Element IdExplanationOfBenefit.payee.type
Definition

Type of Party to be reimbursed: Subscriber, provider, other.

Short DisplayCategory of recipient
Cardinality0..1
Terminology BindingClaim Payee Type Codes (Example)
TypeCodeableConcept
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Summaryfalse
ExplanationOfBenefit.payee.party
Element IdExplanationOfBenefit.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Short DisplayRecipient reference
Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Summaryfalse
Comments

Not required if the payee is 'subscriber' or 'provider'.

ExplanationOfBenefit.referral
Element IdExplanationOfBenefit.referral
Definition

The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Short DisplayTreatment Referral
Cardinality0..1
TypeReference(ServiceRequest)
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Summaryfalse
Comments

The referral resource which lists the date, practitioner, reason and other supporting information.

ExplanationOfBenefit.encounter
Element IdExplanationOfBenefit.encounter
Definition

A billed item may include goods or services provided in multiple encounters.

Short DisplayEncounters related to this billed item
Cardinality0..*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

Summaryfalse
ExplanationOfBenefit.facility
Element IdExplanationOfBenefit.facility
Definition

Facility where the services were provided.

Short DisplayServicing Facility
Cardinality0..1
TypeReference(Location | Organization)
Requirements

Insurance adjudication can be dependant on where services were delivered.

Summaryfalse
ExplanationOfBenefit.claim
Element IdExplanationOfBenefit.claim
Definition

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

Short DisplayClaim reference
Cardinality0..1
TypeReference(Claim)
Requirements

To provide a link to the original adjudication request.

Summaryfalse
ExplanationOfBenefit.claimResponse
Element IdExplanationOfBenefit.claimResponse
Definition

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

Short DisplayClaim response reference
Cardinality0..1
TypeReference(ClaimResponse)
Requirements

To provide a link to the original adjudication response.

Summaryfalse
ExplanationOfBenefit.outcome
Element IdExplanationOfBenefit.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Short Displayqueued | complete | error | partial
Cardinality1..1
Terminology BindingClaim Processing Codes (Required)
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Summarytrue
Comments

The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).

ExplanationOfBenefit.decision
Element IdExplanationOfBenefit.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summarytrue
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.disposition
Element IdExplanationOfBenefit.disposition
Definition

A human readable description of the status of the adjudication.

Short DisplayDisposition Message
Cardinality0..1
Typestring
Requirements

Provided for user display.

Summaryfalse
ExplanationOfBenefit.preAuthRef
Element IdExplanationOfBenefit.preAuthRef
Definition

Reference from the Insurer which is used in later communications which refers to this adjudication.

Short DisplayPreauthorization reference
Cardinality0..*
Typestring
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Summaryfalse
Comments

This value is only present on preauthorization adjudications.

ExplanationOfBenefit.preAuthRefPeriod
Element IdExplanationOfBenefit.preAuthRefPeriod
Definition

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

Short DisplayPreauthorization in-effect period
Cardinality0..*
TypePeriod
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Summaryfalse
Comments

This value is only present on preauthorization adjudications.

ExplanationOfBenefit.diagnosisRelatedGroup
Element IdExplanationOfBenefit.diagnosisRelatedGroup
Definition

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Short DisplayPackage billing code
Cardinality0..1
Terminology BindingExample Diagnosis Related Group Codes (Example)
TypeCodeableConcept
Requirements

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Summaryfalse
Comments

For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

ExplanationOfBenefit.careTeam
Element IdExplanationOfBenefit.careTeam
Definition

The members of the team who provided the products and services.

Short DisplayCare Team members
Cardinality0..*
Requirements

Common to identify the responsible and supporting practitioners.

Summaryfalse
ExplanationOfBenefit.careTeam.sequence
Element IdExplanationOfBenefit.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Short DisplayOrder of care team
Cardinality1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Summaryfalse
ExplanationOfBenefit.careTeam.provider
Element IdExplanationOfBenefit.careTeam.provider
Definition

Member of the team who provided the product or service.

Short DisplayPractitioner or organization
Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Often a regulatory requirement to specify the responsible provider.

Summaryfalse
ExplanationOfBenefit.careTeam.responsible
Element IdExplanationOfBenefit.careTeam.responsible
Definition

The party who is billing and/or responsible for the claimed products or services.

Short DisplayIndicator of the lead practitioner
Cardinality0..1
Typeboolean
Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Summaryfalse
Comments

Responsible might not be required when there is only a single provider listed.

ExplanationOfBenefit.careTeam.role
Element IdExplanationOfBenefit.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Short DisplayFunction within the team
Cardinality0..1
Terminology BindingClaim Care Team Role Codes (Example)
TypeCodeableConcept
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Summaryfalse
Comments

Role might not be required when there is only a single provider listed.

ExplanationOfBenefit.careTeam.specialty
Element IdExplanationOfBenefit.careTeam.specialty
Definition

The specialization of the practitioner or provider which is applicable for this service.

Short DisplayPractitioner or provider specialization
Cardinality0..1
Terminology BindingExample Provider Qualification Codes (Example)
TypeCodeableConcept
Requirements

Need to specify which specialization a practitioner or provider acting under when delivering the product or service.

Summaryfalse
ExplanationOfBenefit.supportingInfo
Element IdExplanationOfBenefit.supportingInfo
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Short DisplaySupporting information
Cardinality0..*
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Summaryfalse
Comments

Often there are multiple jurisdiction specific valuesets which are required.

ExplanationOfBenefit.supportingInfo.sequence
Element IdExplanationOfBenefit.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Short DisplayInformation instance identifier
Cardinality1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Summaryfalse
ExplanationOfBenefit.supportingInfo.category
Element IdExplanationOfBenefit.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Short DisplayClassification of the supplied information
Cardinality1..1
Terminology BindingClaim Information Category Codes (Example)
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Summaryfalse
Comments

This may contain a category for the local bill type codes.

ExplanationOfBenefit.supportingInfo.code
Element IdExplanationOfBenefit.supportingInfo.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Short DisplayType of information
Cardinality0..1
Terminology BindingException Codes (Example)
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Summaryfalse
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

ExplanationOfBenefit.supportingInfo.timing[x]
Element IdExplanationOfBenefit.supportingInfo.timing[x]
Definition

The date when or period to which this information refers.

Short DisplayWhen it occurred
Cardinality0..1
Typedate|Period
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Summaryfalse
ExplanationOfBenefit.supportingInfo.value[x]
Element IdExplanationOfBenefit.supportingInfo.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Short DisplayData to be provided
Cardinality0..1
Typeboolean|string|Quantity|Attachment|Reference(Any)|Identifier
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Summaryfalse
Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

ExplanationOfBenefit.supportingInfo.reason
Element IdExplanationOfBenefit.supportingInfo.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Short DisplayExplanation for the information
Cardinality0..1
Terminology BindingMissing Tooth Reason Codes (Example)
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Summaryfalse
Comments

For example: the reason for the additional stay, or why a tooth is missing.

ExplanationOfBenefit.diagnosis
Element IdExplanationOfBenefit.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Short DisplayPertinent diagnosis information
Cardinality0..*
Requirements

Required for the adjudication by provided context for the services and product listed.

Summaryfalse
ExplanationOfBenefit.diagnosis.sequence
Element IdExplanationOfBenefit.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Short DisplayDiagnosis instance identifier
Cardinality1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Summaryfalse
Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

ExplanationOfBenefit.diagnosis.diagnosis[x]
Element IdExplanationOfBenefit.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Short DisplayNature of illness or problem
Cardinality1..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Provides health context for the evaluation of the products and/or services.

Summaryfalse
ExplanationOfBenefit.diagnosis.type
Element IdExplanationOfBenefit.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Short DisplayTiming or nature of the diagnosis
Cardinality0..*
Terminology BindingExample Diagnosis Type Codes (Example)
TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Summaryfalse
Comments

For example: admitting, primary, secondary, discharge.

ExplanationOfBenefit.diagnosis.onAdmission
Element IdExplanationOfBenefit.diagnosis.onAdmission
Definition

Indication of whether the diagnosis was present on admission to a facility.

Short DisplayPresent on admission
Cardinality0..1
Terminology BindingExample Diagnosis on Admission Codes (Example)
TypeCodeableConcept
Requirements

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

Summaryfalse
ExplanationOfBenefit.procedure
Element IdExplanationOfBenefit.procedure
Definition

Procedures performed on the patient relevant to the billing items with the claim.

Short DisplayClinical procedures performed
Cardinality0..*
Requirements

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

Summaryfalse
ExplanationOfBenefit.procedure.sequence
Element IdExplanationOfBenefit.procedure.sequence
Definition

A number to uniquely identify procedure entries.

Short DisplayProcedure instance identifier
Cardinality1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to claim details.

Summaryfalse
ExplanationOfBenefit.procedure.type
Element IdExplanationOfBenefit.procedure.type
Definition

When the condition was observed or the relative ranking.

Short DisplayCategory of Procedure
Cardinality0..*
Terminology BindingExample Procedure Type Codes (Example)
TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Summaryfalse
ExplanationOfBenefit.procedure.date
Element IdExplanationOfBenefit.procedure.date
Definition

Date and optionally time the procedure was performed.

Short DisplayWhen the procedure was performed
Cardinality0..1
TypedateTime
Requirements

Required for auditing purposes.

Summaryfalse
ExplanationOfBenefit.procedure.procedure[x]
Element IdExplanationOfBenefit.procedure.procedure[x]
Definition

The code or reference to a Procedure resource which identifies the clinical intervention performed.

Short DisplaySpecific clinical procedure
Cardinality1..1
Terminology BindingICD-10 Procedure Codes (Example)
TypeCodeableConcept|Reference(Procedure)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

This identifies the actual clinical procedure.

Summaryfalse
ExplanationOfBenefit.procedure.udi
Element IdExplanationOfBenefit.procedure.udi
Definition

Unique Device Identifiers associated with this line item.

Short DisplayUnique device identifier
Cardinality0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Summaryfalse
ExplanationOfBenefit.precedence
Element IdExplanationOfBenefit.precedence
Definition

This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.

Short DisplayPrecedence (primary, secondary, etc.)
Cardinality0..1
TypepositiveInt
Requirements

Needed to coordinate between multiple EOBs for the same suite of services.

Summaryfalse
ExplanationOfBenefit.insurance
Element IdExplanationOfBenefit.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Short DisplayPatient insurance information
Cardinality0..*
Requirements

At least one insurer is required for a claim to be a claim.

Summarytrue
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

ExplanationOfBenefit.insurance.focal
Element IdExplanationOfBenefit.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Short DisplayCoverage to be used for adjudication
Cardinality1..1
Typeboolean
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Summarytrue
Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

ExplanationOfBenefit.insurance.coverage
Element IdExplanationOfBenefit.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Short DisplayInsurance information
Cardinality1..1
TypeReference(Coverage)
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Summarytrue
ExplanationOfBenefit.insurance.preAuthRef
Element IdExplanationOfBenefit.insurance.preAuthRef
Definition

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Short DisplayPrior authorization reference number
Cardinality0..*
Typestring
Requirements

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Summaryfalse
Comments

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

ExplanationOfBenefit.accident
Element IdExplanationOfBenefit.accident
Definition

Details of a accident which resulted in injuries which required the products and services listed in the claim.

Short DisplayDetails of the event
Cardinality0..1
Requirements

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

Summaryfalse
ExplanationOfBenefit.accident.date
Element IdExplanationOfBenefit.accident.date
Definition

Date of an accident event related to the products and services contained in the claim.

Short DisplayWhen the incident occurred
Cardinality0..1
Typedate
Requirements

Required for audit purposes and adjudication.

Summaryfalse
Comments

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

ExplanationOfBenefit.accident.type
Element IdExplanationOfBenefit.accident.type
Definition

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Short DisplayThe nature of the accident
Cardinality0..1
Terminology BindingActIncidentCode icon (Extensible)
TypeCodeableConcept
Requirements

Coverage may be dependant on the type of accident.

Summaryfalse
ExplanationOfBenefit.accident.location[x]
Element IdExplanationOfBenefit.accident.location[x]
Definition

The physical location of the accident event.

Short DisplayWhere the event occurred
Cardinality0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Required for audit purposes and determination of applicable insurance liability.

Summaryfalse
ExplanationOfBenefit.patientPaid
Element IdExplanationOfBenefit.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.item
Element IdExplanationOfBenefit.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Short DisplayProduct or service provided
Cardinality0..*
Requirements

The items to be processed for adjudication.

Summaryfalse
ExplanationOfBenefit.item.sequence
Element IdExplanationOfBenefit.item.sequence
Definition

A number to uniquely identify item entries.

Short DisplayItem instance identifier
Cardinality1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Summaryfalse
ExplanationOfBenefit.item.careTeamSequence
Element IdExplanationOfBenefit.item.careTeamSequence
Definition

Care team members related to this service or product.

Short DisplayApplicable care team members
Cardinality0..*
TypepositiveInt
Requirements

Need to identify the individuals and their roles in the provision of the product or service.

Summaryfalse
ExplanationOfBenefit.item.diagnosisSequence
Element IdExplanationOfBenefit.item.diagnosisSequence
Definition

Diagnoses applicable for this service or product.

Short DisplayApplicable diagnoses
Cardinality0..*
TypepositiveInt
Requirements

Need to related the product or service to the associated diagnoses.

Summaryfalse
ExplanationOfBenefit.item.procedureSequence
Element IdExplanationOfBenefit.item.procedureSequence
Definition

Procedures applicable for this service or product.

Short DisplayApplicable procedures
Cardinality0..*
TypepositiveInt
Requirements

Need to provide any listed specific procedures to support the product or service being claimed.

Summaryfalse
ExplanationOfBenefit.item.informationSequence
Element IdExplanationOfBenefit.item.informationSequence
Definition

Exceptions, special conditions and supporting information applicable for this service or product.

Short DisplayApplicable exception and supporting information
Cardinality0..*
TypepositiveInt
Requirements

Need to reference the supporting information items that relate directly to this product or service.

Summaryfalse
ExplanationOfBenefit.item.revenue
Element IdExplanationOfBenefit.item.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.item.category
Element IdExplanationOfBenefit.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Summaryfalse
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.productOrService
Element IdExplanationOfBenefit.item.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.productOrServiceEnd
Element IdExplanationOfBenefit.item.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.item.modifier
Element IdExplanationOfBenefit.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayProduct or service billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.item.programCode
Element IdExplanationOfBenefit.item.programCode
Definition

Identifies the program under which this may be recovered.

Short DisplayProgram the product or service is provided under
Cardinality0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Summaryfalse
Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.serviced[x]
Element IdExplanationOfBenefit.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Short DisplayDate or dates of service or product delivery
Cardinality0..1
Typedate|Period
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Summaryfalse
ExplanationOfBenefit.item.location[x]
Element IdExplanationOfBenefit.item.location[x]
Definition

Where the product or service was provided.

Short DisplayPlace of service or where product was supplied
Cardinality0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Summaryfalse
ExplanationOfBenefit.item.patientPaid
Element IdExplanationOfBenefit.item.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.item.quantity
Element IdExplanationOfBenefit.item.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.item.unitPrice
Element IdExplanationOfBenefit.item.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.item.factor
Element IdExplanationOfBenefit.item.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.tax
Element IdExplanationOfBenefit.item.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.item.net
Element IdExplanationOfBenefit.item.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.udi
Element IdExplanationOfBenefit.item.udi
Definition

Unique Device Identifiers associated with this line item.

Short DisplayUnique device identifier
Cardinality0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Summaryfalse
ExplanationOfBenefit.item.bodySite
Element IdExplanationOfBenefit.item.bodySite
Definition

Physical location where the service is performed or applies.

Short DisplayAnatomical location
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.item.bodySite.site
Element IdExplanationOfBenefit.item.bodySite.site
Definition

Physical service site on the patient (limb, tooth, etc.).

Short DisplayLocation
Cardinality1..*
Terminology BindingOral Site Codes (Example)
TypeCodeableReference(BodyStructure)
Requirements

Allows insurer to validate specific procedures.

Summaryfalse
Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

ExplanationOfBenefit.item.bodySite.subSite
Element IdExplanationOfBenefit.item.bodySite.subSite
Definition

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Short DisplaySub-location
Cardinality0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Summaryfalse
ExplanationOfBenefit.item.encounter
Element IdExplanationOfBenefit.item.encounter
Definition

A billed item may include goods or services provided in multiple encounters.

Short DisplayEncounters related to this billed item
Cardinality0..*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

Summaryfalse
ExplanationOfBenefit.item.noteNumber
Element IdExplanationOfBenefit.item.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.item.decision
Element IdExplanationOfBenefit.item.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.item.adjudication
Element IdExplanationOfBenefit.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Short DisplayAdjudication details
Cardinality0..*
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Summaryfalse
ExplanationOfBenefit.item.adjudication.category
Element IdExplanationOfBenefit.item.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Short DisplayType of adjudication information
Cardinality1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Summaryfalse
Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

ExplanationOfBenefit.item.adjudication.reason
Element IdExplanationOfBenefit.item.adjudication.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Short DisplayExplanation of adjudication outcome
Cardinality0..1
Terminology BindingAdjudication Reason Codes (Example)
TypeCodeableConcept
Requirements

To support understanding of variance from adjudication expectations.

Summaryfalse
Comments

For example, may indicate that the funds for this benefit type have been exhausted.

ExplanationOfBenefit.item.adjudication.amount
Element IdExplanationOfBenefit.item.adjudication.amount
Definition

Monetary amount associated with the category.

Short DisplayMonetary amount
Cardinality0..1
TypeMoney
Requirements

Most adjudication categories convey a monetary amount.

Summaryfalse
Comments

For example, amount submitted, eligible amount, co-payment, and benefit payable.

ExplanationOfBenefit.item.adjudication.value
Element IdExplanationOfBenefit.item.adjudication.value
Definition

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Short DisplayNon-monitary value
Cardinality0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Summaryfalse
Comments

For example: eligible percentage or co-payment percentage.

ExplanationOfBenefit.item.detail
Element IdExplanationOfBenefit.item.detail
Definition

Second-tier of goods and services.

Short DisplayAdditional items
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.item.detail.sequence
Element IdExplanationOfBenefit.item.detail.sequence
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Short DisplayProduct or service provided
Cardinality1..1
TypepositiveInt
Requirements

The items to be processed for adjudication.

Summaryfalse
ExplanationOfBenefit.item.detail.revenue
Element IdExplanationOfBenefit.item.detail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.item.detail.category
Element IdExplanationOfBenefit.item.detail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Summaryfalse
Comments

Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.detail.productOrService
Element IdExplanationOfBenefit.item.detail.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.detail.productOrServiceEnd
Element IdExplanationOfBenefit.item.detail.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.item.detail.modifier
Element IdExplanationOfBenefit.item.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayService/Product billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.item.detail.programCode
Element IdExplanationOfBenefit.item.detail.programCode
Definition

Identifies the program under which this may be recovered.

Short DisplayProgram the product or service is provided under
Cardinality0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Summaryfalse
Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.detail.patientPaid
Element IdExplanationOfBenefit.item.detail.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.item.detail.quantity
Element IdExplanationOfBenefit.item.detail.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.item.detail.unitPrice
Element IdExplanationOfBenefit.item.detail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.item.detail.factor
Element IdExplanationOfBenefit.item.detail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.detail.tax
Element IdExplanationOfBenefit.item.detail.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.item.detail.net
Element IdExplanationOfBenefit.item.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.detail.udi
Element IdExplanationOfBenefit.item.detail.udi
Definition

Unique Device Identifiers associated with this line item.

Short DisplayUnique device identifier
Cardinality0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Summaryfalse
ExplanationOfBenefit.item.detail.noteNumber
Element IdExplanationOfBenefit.item.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.item.detail.decision
Element IdExplanationOfBenefit.item.detail.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.item.detail.adjudication
Element IdExplanationOfBenefit.item.detail.adjudication
Definition

The adjudication results.

Short DisplayDetail level adjudication details
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Summaryfalse
ExplanationOfBenefit.item.detail.subDetail
Element IdExplanationOfBenefit.item.detail.subDetail
Definition

Third-tier of goods and services.

Short DisplayAdditional items
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.sequence
Element IdExplanationOfBenefit.item.detail.subDetail.sequence
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Short DisplayProduct or service provided
Cardinality1..1
TypepositiveInt
Requirements

The items to be processed for adjudication.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.revenue
Element IdExplanationOfBenefit.item.detail.subDetail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.category
Element IdExplanationOfBenefit.item.detail.subDetail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Summaryfalse
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.detail.subDetail.productOrService
Element IdExplanationOfBenefit.item.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
Element IdExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.modifier
Element IdExplanationOfBenefit.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayService/Product billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

ExplanationOfBenefit.item.detail.subDetail.programCode
Element IdExplanationOfBenefit.item.detail.subDetail.programCode
Definition

Identifies the program under which this may be recovered.

Short DisplayProgram the product or service is provided under
Cardinality0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Summaryfalse
Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.detail.subDetail.patientPaid
Element IdExplanationOfBenefit.item.detail.subDetail.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.quantity
Element IdExplanationOfBenefit.item.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.item.detail.subDetail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.factor
Element IdExplanationOfBenefit.item.detail.subDetail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.detail.subDetail.tax
Element IdExplanationOfBenefit.item.detail.subDetail.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.net
Element IdExplanationOfBenefit.item.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.detail.subDetail.udi
Element IdExplanationOfBenefit.item.detail.subDetail.udi
Definition

Unique Device Identifiers associated with this line item.

Short DisplayUnique device identifier
Cardinality0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.item.detail.subDetail.decision
Element IdExplanationOfBenefit.item.detail.subDetail.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.item.detail.subDetail.adjudication
Element IdExplanationOfBenefit.item.detail.subDetail.adjudication
Definition

The adjudication results.

Short DisplaySubdetail level adjudication details
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Summaryfalse
ExplanationOfBenefit.addItem
Element IdExplanationOfBenefit.addItem
Definition

The first-tier service adjudications for payor added product or service lines.

Short DisplayInsurer added line items
Cardinality0..*
Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Summaryfalse
ExplanationOfBenefit.addItem.itemSequence
Element IdExplanationOfBenefit.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

Short DisplayItem sequence number
Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim items.

Summaryfalse
ExplanationOfBenefit.addItem.detailSequence
Element IdExplanationOfBenefit.addItem.detailSequence
Definition

The sequence number of the details within the claim item which this line is intended to replace.

Short DisplayDetail sequence number
Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

Summaryfalse
ExplanationOfBenefit.addItem.subDetailSequence
Element IdExplanationOfBenefit.addItem.subDetailSequence
Definition

The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

Short DisplaySubdetail sequence number
Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim sub-details within the claim detail.

Summaryfalse
ExplanationOfBenefit.addItem.provider
Element IdExplanationOfBenefit.addItem.provider
Definition

The providers who are authorized for the services rendered to the patient.

Short DisplayAuthorized providers
Cardinality0..*
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Summaryfalse
ExplanationOfBenefit.addItem.revenue
Element IdExplanationOfBenefit.addItem.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.addItem.productOrService
Element IdExplanationOfBenefit.addItem.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.productOrServiceEnd
Element IdExplanationOfBenefit.addItem.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.addItem.modifier
Element IdExplanationOfBenefit.addItem.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayService/Product billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.programCode
Element IdExplanationOfBenefit.addItem.programCode
Definition

Identifies the program under which this may be recovered.

Short DisplayProgram the product or service is provided under
Cardinality0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Summaryfalse
Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.addItem.serviced[x]
Element IdExplanationOfBenefit.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Short DisplayDate or dates of service or product delivery
Cardinality0..1
Typedate|Period
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Summaryfalse
ExplanationOfBenefit.addItem.location[x]
Element IdExplanationOfBenefit.addItem.location[x]
Definition

Where the product or service was provided.

Short DisplayPlace of service or where product was supplied
Cardinality0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Summaryfalse
ExplanationOfBenefit.addItem.patientPaid
Element IdExplanationOfBenefit.addItem.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.addItem.quantity
Element IdExplanationOfBenefit.addItem.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.addItem.unitPrice
Element IdExplanationOfBenefit.addItem.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.addItem.factor
Element IdExplanationOfBenefit.addItem.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.tax
Element IdExplanationOfBenefit.addItem.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.addItem.net
Element IdExplanationOfBenefit.addItem.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.bodySite
Element IdExplanationOfBenefit.addItem.bodySite
Definition

Physical location where the service is performed or applies.

Short DisplayAnatomical location
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.addItem.bodySite.site
Element IdExplanationOfBenefit.addItem.bodySite.site
Definition

Physical service site on the patient (limb, tooth, etc.).

Short DisplayLocation
Cardinality1..*
Terminology BindingOral Site Codes (Example)
TypeCodeableReference(BodyStructure)
Requirements

Allows insurer to validate specific procedures.

Summaryfalse
Comments

For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

ExplanationOfBenefit.addItem.bodySite.subSite
Element IdExplanationOfBenefit.addItem.bodySite.subSite
Definition

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Short DisplaySub-location
Cardinality0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Summaryfalse
ExplanationOfBenefit.addItem.noteNumber
Element IdExplanationOfBenefit.addItem.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.addItem.decision
Element IdExplanationOfBenefit.addItem.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.addItem.adjudication
Element IdExplanationOfBenefit.addItem.adjudication
Definition

The adjudication results.

Short DisplayAdded items adjudication
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Summaryfalse
ExplanationOfBenefit.addItem.detail
Element IdExplanationOfBenefit.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Short DisplayInsurer added line items
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.addItem.detail.revenue
Element IdExplanationOfBenefit.addItem.detail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.addItem.detail.productOrService
Element IdExplanationOfBenefit.addItem.detail.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.detail.productOrServiceEnd
Element IdExplanationOfBenefit.addItem.detail.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.addItem.detail.modifier
Element IdExplanationOfBenefit.addItem.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayService/Product billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.detail.patientPaid
Element IdExplanationOfBenefit.addItem.detail.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.addItem.detail.quantity
Element IdExplanationOfBenefit.addItem.detail.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.addItem.detail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.addItem.detail.factor
Element IdExplanationOfBenefit.addItem.detail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.detail.tax
Element IdExplanationOfBenefit.addItem.detail.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.addItem.detail.net
Element IdExplanationOfBenefit.addItem.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.detail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.addItem.detail.decision
Element IdExplanationOfBenefit.addItem.detail.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.addItem.detail.adjudication
Element IdExplanationOfBenefit.addItem.detail.adjudication
Definition

The adjudication results.

Short DisplayAdded items adjudication
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail
Element IdExplanationOfBenefit.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Short DisplayInsurer added line items
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.revenue
Element IdExplanationOfBenefit.addItem.detail.subDetail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Short DisplayRevenue or cost center code
Cardinality0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
Element IdExplanationOfBenefit.addItem.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
Element IdExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
Definition

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Short DisplayEnd of a range of codes
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Alternate NamesEnd of a range of Drug Code; Bill Code; Service Cod
Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.modifier
Element IdExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayService/Product billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Summaryfalse
Comments

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
Element IdExplanationOfBenefit.addItem.detail.subDetail.patientPaid
Definition

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Short DisplayPaid by the patient
Cardinality0..1
TypeMoney
Requirements

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.quantity
Element IdExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Short DisplayCount of products or services
Cardinality0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Short DisplayFee, charge or cost per item
Cardinality0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.factor
Element IdExplanationOfBenefit.addItem.detail.subDetail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Short DisplayPrice scaling factor
Cardinality0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Summaryfalse
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.detail.subDetail.tax
Element IdExplanationOfBenefit.addItem.detail.subDetail.tax
Definition

The total of taxes applicable for this product or service.

Short DisplayTotal tax
Cardinality0..1
TypeMoney
Requirements

Required when taxes are not embedded in the unit price or provided as a separate service.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.net
Element IdExplanationOfBenefit.addItem.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Short DisplayTotal item cost
Cardinality0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Summaryfalse
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Short DisplayApplicable note numbers
Cardinality0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Summaryfalse
ExplanationOfBenefit.addItem.detail.subDetail.decision
Element IdExplanationOfBenefit.addItem.detail.subDetail.decision
Definition

The result of the claim, predetermination, or preauthorization adjudication.

Short DisplayResult of the adjudication
Cardinality0..1
Terminology BindingClaim Adjudication Decision Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor of the result of the adjudication process.

Summaryfalse
Comments

The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Element IdExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Short DisplayAdded items adjudication
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Summaryfalse
ExplanationOfBenefit.adjudication
Element IdExplanationOfBenefit.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Short DisplayHeader-level adjudication
Cardinality0..*
TypeSee ExplanationOfBenefit.item.adjudication
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Summaryfalse
ExplanationOfBenefit.total
Element IdExplanationOfBenefit.total
Definition

Categorized monetary totals for the adjudication.

Short DisplayAdjudication totals
Cardinality0..*
Requirements

To provide the requestor with financial totals by category for the adjudication.

Summarytrue
Comments

Totals for amounts submitted, co-pays, benefits payable etc.

ExplanationOfBenefit.total.category
Element IdExplanationOfBenefit.total.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Short DisplayType of adjudication information
Cardinality1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the type of total provided.

Summarytrue
Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

ExplanationOfBenefit.total.amount
Element IdExplanationOfBenefit.total.amount
Definition

Monetary total amount associated with the category.

Short DisplayFinancial total for the category
Cardinality1..1
TypeMoney
Requirements

Needed to convey the total monetary amount.

Summarytrue
ExplanationOfBenefit.payment
Element IdExplanationOfBenefit.payment
Definition

Payment details for the adjudication of the claim.

Short DisplayPayment Details
Cardinality0..1
Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

Summaryfalse
ExplanationOfBenefit.payment.type
Element IdExplanationOfBenefit.payment.type
Definition

Whether this represents partial or complete payment of the benefits payable.

Short DisplayPartial or complete payment
Cardinality0..1
Terminology BindingExample Payment Type Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor when the insurer believes all payments to have been completed.

Summaryfalse
ExplanationOfBenefit.payment.adjustment
Element IdExplanationOfBenefit.payment.adjustment
Definition

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

Short DisplayPayment adjustment for non-claim issues
Cardinality0..1
TypeMoney
Requirements

To advise the requestor of adjustments applied to the payment.

Summaryfalse
Comments

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

ExplanationOfBenefit.payment.adjustmentReason
Element IdExplanationOfBenefit.payment.adjustmentReason
Definition

Reason for the payment adjustment.

Short DisplayExplanation for the variance
Cardinality0..1
Terminology BindingPayment Adjustment Reason Codes (Example)
TypeCodeableConcept
Requirements

Needed to clarify the monetary adjustment.

Summaryfalse
ExplanationOfBenefit.payment.date
Element IdExplanationOfBenefit.payment.date
Definition

Estimated date the payment will be issued or the actual issue date of payment.

Short DisplayExpected date of payment
Cardinality0..1
Typedate
Requirements

To advise the payee when payment can be expected.

Summaryfalse
ExplanationOfBenefit.payment.amount
Element IdExplanationOfBenefit.payment.amount
Definition

Benefits payable less any payment adjustment.

Short DisplayPayable amount after adjustment
Cardinality0..1
TypeMoney
Requirements

Needed to provide the actual payment amount.

Summaryfalse
ExplanationOfBenefit.payment.identifier
Element IdExplanationOfBenefit.payment.identifier
Definition

Issuer's unique identifier for the payment instrument.

Short DisplayBusiness identifier for the payment
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..1
TypeIdentifier
Requirements

Enable the receiver to reconcile when payment received.

Summaryfalse
Comments

For example: EFT number or check number.

ExplanationOfBenefit.formCode
Element IdExplanationOfBenefit.formCode
Definition

A code for the form to be used for printing the content.

Short DisplayPrinted form identifier
Cardinality0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
Requirements

Needed to specify the specific form used for producing output for this response.

Summaryfalse
Comments

May be needed to identify specific jurisdictional forms.

ExplanationOfBenefit.form
Element IdExplanationOfBenefit.form
Definition

The actual form, by reference or inclusion, for printing the content or an EOB.

Short DisplayPrinted reference or actual form
Cardinality0..1
TypeAttachment
Requirements

Needed to include the specific form used for producing output for this response.

Summaryfalse
Comments

Needed to permit insurers to include the actual form.

ExplanationOfBenefit.processNote
Element IdExplanationOfBenefit.processNote
Definition

A note that describes or explains adjudication results in a human readable form.

Short DisplayNote concerning adjudication
Cardinality0..*
Requirements

Provides the insurer specific textual explanations associated with the processing.

Summaryfalse
ExplanationOfBenefit.processNote.number
Element IdExplanationOfBenefit.processNote.number
Definition

A number to uniquely identify a note entry.

Short DisplayNote instance identifier
Cardinality0..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link from adjudications.

Summaryfalse
ExplanationOfBenefit.processNote.type
Element IdExplanationOfBenefit.processNote.type
Definition

The business purpose of the note text.

Short Displaydisplay | print | printoper
Cardinality0..1
Terminology BindingNoteType (Required)
Typecode
Requirements

To convey the expectation for when the text is used.

Summaryfalse
ExplanationOfBenefit.processNote.text
Element IdExplanationOfBenefit.processNote.text
Definition

The explanation or description associated with the processing.

Short DisplayNote explanatory text
Cardinality0..1
Typestring
Requirements

Required to provide human readable explanation.

Summaryfalse
ExplanationOfBenefit.processNote.language
Element IdExplanationOfBenefit.processNote.language
Definition

A code to define the language used in the text of the note.

Short DisplayLanguage of the text
Cardinality0..1
Terminology BindingCommon Languages (Preferred but limited to All Languages)
TypeCodeableConcept
Requirements

Note text may vary from the resource defined language.

Summaryfalse
Comments

Only required if the language is different from the resource language.

ExplanationOfBenefit.benefitPeriod
Element IdExplanationOfBenefit.benefitPeriod
Definition

The term of the benefits documented in this response.

Short DisplayWhen the benefits are applicable
Cardinality0..1
TypePeriod
Requirements

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Summaryfalse
Comments

Not applicable when use=claim.

ExplanationOfBenefit.benefitBalance
Element IdExplanationOfBenefit.benefitBalance
Definition

Balance by Benefit Category.

Short DisplayBalance by Benefit Category
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.benefitBalance.category
Element IdExplanationOfBenefit.benefitBalance.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality1..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Summaryfalse
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.benefitBalance.excluded
Element IdExplanationOfBenefit.benefitBalance.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Short DisplayExcluded from the plan
Cardinality0..1
Typeboolean
Requirements

Needed to identify items that are specifically excluded from the coverage.

Summaryfalse
ExplanationOfBenefit.benefitBalance.name
Element IdExplanationOfBenefit.benefitBalance.name
Definition

A short name or tag for the benefit.

Short DisplayShort name for the benefit
Cardinality0..1
Typestring
Requirements

Required to align with other plan names.

Summaryfalse
Comments

For example: MED01, or DENT2.

ExplanationOfBenefit.benefitBalance.description
Element IdExplanationOfBenefit.benefitBalance.description
Definition

A richer description of the benefit or services covered.

Short DisplayDescription of the benefit or services covered
Cardinality0..1
Typestring
Requirements

Needed for human readable reference.

Summaryfalse
Comments

For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

ExplanationOfBenefit.benefitBalance.network
Element IdExplanationOfBenefit.benefitBalance.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Short DisplayIn or out of network
Cardinality0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
Requirements

Needed as in or out of network providers are treated differently under the coverage.

Summaryfalse
ExplanationOfBenefit.benefitBalance.unit
Element IdExplanationOfBenefit.benefitBalance.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Short DisplayIndividual or family
Cardinality0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

Summaryfalse
ExplanationOfBenefit.benefitBalance.term
Element IdExplanationOfBenefit.benefitBalance.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Short DisplayAnnual or lifetime
Cardinality0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

Summaryfalse
ExplanationOfBenefit.benefitBalance.financial
Element IdExplanationOfBenefit.benefitBalance.financial
Definition

Benefits Used to date.

Short DisplayBenefit Summary
Cardinality0..*
Summaryfalse
ExplanationOfBenefit.benefitBalance.financial.type
Element IdExplanationOfBenefit.benefitBalance.financial.type
Definition

Classification of benefit being provided.

Short DisplayBenefit classification
Cardinality1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the nature of the benefit.

Summaryfalse
Comments

For example: deductible, visits, benefit amount.

ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Element IdExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition

The quantity of the benefit which is permitted under the coverage.

Short DisplayBenefits allowed
Cardinality0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to convey the benefits offered under the coverage.

Summaryfalse
ExplanationOfBenefit.benefitBalance.financial.used[x]
Element IdExplanationOfBenefit.benefitBalance.financial.used[x]
Definition

The quantity of the benefit which have been consumed to date.

Short DisplayBenefits used
Cardinality0..1
TypeunsignedInt|Money
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to convey the benefits consumed to date.

Summaryfalse