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

The Response Business Identifier.

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.

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

The version of the specification on which this instance relies.

The version of the specification from which the original instance was created.

The date when the EOB was created.

The billable period for which charges are being submitted.

A description of the status of the adjudication.

Do we need a disposition code?

The provider which is responsible for the claim.

The provider which is responsible for the claim.

Facility where the services were provided.

Other claims which are related to this claim such as prior claim versions or for related services.

Other claims which are related to this claim such as prior claim versions or for related services.

Do we need a relationship code?

For example prior or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .

Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.

The party to be reimbursed for the services.

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

Party to be reimbursed: Subscriber, provider, other.

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

**Insert definition of Occurrence codes.

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

**Insert definition of Occurrence Span codes.

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

**Insert definition of Value codes.

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

Ordered list of patient diagnosis for which care is sought.

Sequence of diagnosis which serves to order and provide a link.

Required to maintain order of the diagnoses.

The diagnosis.

Required to adjudicate services rendered to condition presented.

Ordered list of patient procedures performed to support the adjudication.

Sequence of procedures which serves to order and provide a link.

Required to maintain order of the procudures.

Date and optionally time the procedure was performed .

Required to adjudicate services rendered.

SB DateTime??

The procedure code.

Required to adjudicate services rendered.

List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.

Patient Resource.

Precedence (primary, secondary, etc.).

Health care programs and insurers are significant payors of health service costs.

Financial instrument by which payment information for health care.

Health care programs and insurers are significant payors of health service costs.

Reference to the program or plan identification, underwriter or payor.

Need to identify the issuer to target for processing and for coordination of benefit processing.

A list of references from the Insurer to which these services pertain.

To provide any pre=determination or prior authorization reference.

Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

Type of accident: work, auto, etc.

Coverage may be dependant on the type of accident.

Accident Place.

A list of intervention and exception codes which may influence the adjudication of the claim.

Coverage may be modified based on exception information provided.

Period, start and last dates of aspects of the Condition or related services.

The start or start and end dates for the treatable condition.

Onset typifications eg. Start of pregnancy, start of illnes, etc.

The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).

The start and optional end dates of when the patient was confined to a treatment center.

First tier of goods and services.

A service line number.

The type of product or service.

The practitioner who is responsible for the services rendered to the patient.

The practitioner who is supervising the work of the servicing provider(s).

The qualification which is applicable for this service.

Diagnosis applicable for this service or product line.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

Unusual circumstances which may influence adjudication.

May impact on adjudication.

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

May impact on adjudication.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The date or dates when the enclosed suite of services were performed or completed.

Where the service was provided.

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

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.

If a fee is present the associated product/service code must be present.

An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

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

A region or surface of the site, eg. limb region or tooth surface(s).

A list of note references to the notes provided below.

The adjudications results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Second tier of goods and services.

A service line number.

The type of product or service.

ItemType.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present.

An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

The adjudications results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Third tier of goods and services.

A service line number.

The type of product or service.

The fee for an addittional service or product or charge.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The number of repetitions of a service or product.

The fee for an addittional service or product or charge.

If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present.

An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

The adjudications results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The materials and placement date of prior fixed prosthesis.

Indicates whether this is the initial placement of a fixed prosthesis.

May impact on adjudication.

Date of the initial placement.

May impact on adjudication.

Material of the prior denture or bridge prosthesis. (Oral).

May impact on adjudication.

The first tier service adjudications for payor added services.

List of input service items which this service line is intended to replace.

A code to indicate the Professional Service or Product supplied.

The fee charged for the professional service or product..

A list of note references to the notes provided below.

The adjudications results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The second tier service adjudications for payor added services.

A code to indicate the Professional Service or Product supplied.

The fee charged for the professional service or product..

The adjudications results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.

The list of missing teeth may influence the adjudication of services for example with Bridges.

The code identifying which tooth is missing.

Provides the tooth number of the missing tooth.

Missing reason may be: E-extraction, O-other.

Provides the reason for the missing tooth.

The date of the extraction either known from records or patient reported estimate.

Some services and adjudications require this information.

The total cost of the services reported.

This is a check value that the receiver calculates and returns.

The amount of deductable applied which was not allocated to any particular service line.

Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).

Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Reason for the payment adjustment.

Estimated payment data.

Payable less any payment adjustment.

Payment identifer.

Status of funds reservation (For provider, for Patient, None).

The form to be used for printing the content.

Note text.

An integer associated with each note which may be referred to from each service line item.

The note purpose: Print/Display.

The note text.

Balance by Benefit Category.

Dental, Vision, Medical, Pharmacy, Rehab etc.

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Network designation.

Unit designation: individual or family.

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

Benefits Used to date.

Deductable, visits, benefit amount.

Benefits allowed.

Benefits used.