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This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

7.6 Resource ExplanationOfBenefit - Content

This resource is marked as a draft.

Financial Management Work GroupMaturity Level: 0Compartments: Not linked to any defined compartments

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.

7.6.1 Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft.

The ExplanationOfBenefit resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patients coverage in respect of that Claim.

This is the logical combination of the Claim, Claim Response and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage used and/or remaining.

Todo

7.6.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit ΣDomainResourceRemittance resource
... identifier Σ0..*IdentifierBusiness Identifier
... request Σ0..1Reference(Claim)Claim reference
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization Σ0..1Reference(Organization)Insurer
... requestProvider Σ0..1Reference(Practitioner)Responsible practitioner
... requestOrganization Σ0..1Reference(Organization)Responsible organization

doco Documentation for this format

XML Template

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <request><!-- 0..1 Reference(Claim) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</ExplanationOfBenefit>

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit ΣDomainResourceRemittance resource
... identifier Σ0..*IdentifierBusiness Identifier
... request Σ0..1Reference(Claim)Claim reference
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization Σ0..1Reference(Organization)Insurer
... requestProvider Σ0..1Reference(Practitioner)Responsible practitioner
... requestOrganization Σ0..1Reference(Organization)Responsible organization

doco Documentation for this format

XML Template

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <request><!-- 0..1 Reference(Claim) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</ExplanationOfBenefit>

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.6.2.1 Terminology Bindings

PathDefinitionTypeReference
ExplanationOfBenefit.outcome The outcome of the processing.RequiredRemittanceOutcome
ExplanationOfBenefit.ruleset
ExplanationOfBenefit.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.ExampleRuleset Codes

7.6.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier