DHIN 2025Connectathon FHIR IG
0.1.0 - draft

DHIN 2025Connectathon FHIR IG, published by DHIN. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Nigeria-FHIR-Community/2025Connectathon/ and changes regularly. See the Directory of published versions

Resource Profile: NG ExplanationOfBenefit

Official URL: https://sandbox.dhin-hie.org/ig/StructureDefinition/ng-explanationofbenefit Version: 0.1.0
Draft as of 2025-10-21 Computable Name: NgExplanationOfBenefit

A profile detailing adjudicated claim results.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... insurance Σ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... status S 1..1 code active | cancelled | draft | entered-in-error
... type S 1..1 CodeableConcept Category or discipline
... patient S 1..1 Reference(Patient) The recipient of the products and services
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for the resource
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam 0..* BackboneElement Care Team members
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance Σ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... adjudication 0..* See adjudication (ExplanationOfBenefit) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payee.type Base example PayeeType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​total.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​formCode Base example Forms 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.type Base required NoteType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.network Base example Network Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ExplanationOfBenefit

Summary

Must-Support: 5 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... insurance Σ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... status S 1..1 code active | cancelled | draft | entered-in-error
... type S 1..1 CodeableConcept Category or discipline
... patient S 1..1 Reference(Patient) The recipient of the products and services
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for the resource
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam 0..* BackboneElement Care Team members
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance Σ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... adjudication 0..* See adjudication (ExplanationOfBenefit) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payee.type Base example PayeeType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​total.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​formCode Base example Forms 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.type Base required NoteType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.network Base example Network Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ExplanationOfBenefit

Summary

Must-Support: 5 elements

 

Other representations of profile: CSV, Excel, Schematron