STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 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 ΣDomainResourceExplanation of Benefit resource
... identifier Σ0..*IdentifierBusiness Identifier
... claim[x] Σ0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] Σ0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... disposition Σ0..1stringDisposition Message
... provider[x] Σ0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence Σ0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage Σ1..1BackboneElementInsurance or medical plan
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..*Reference(Device)Unique Device Identifier
..... adjudication Σ0..*BackboneElementDetail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..*Reference(Device)Unique Device Identifier
...... adjudication Σ0..*BackboneElementSubDetail adjudication
....... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monitory value
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductable
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanitory text
... benefitBalance Σ0..*BackboneElementBalance by Benefit Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney

doco Documentation for this format

UML Diagram

ExplanationOfBenefit (DomainResource)The Response Business Identifieridentifier : Identifier [0..*]The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaim[x] : Type [0..1] « Identifier|Reference(Claim) »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaimResponse[x] : Type [0..1] « Identifier|Reference(ClaimResponse) »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : Coding [0..*] « A more granulat claim typecode (Strength=Example)Example Claim SubType ?? »The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the EOB was createdcreated : dateTime [0..1]The billable period for which charges are being submittedbillablePeriod : Period [0..1]A description of the status of the adjudicationdisposition : string [0..1]The provider which is responsible for the claimprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The provider which is responsible for the claimorganization[x] : Type [0..1] « Identifier|Reference(Organization) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Prescription to support the dispensing of Pharmacy or Vision productsprescription[x] : Type [0..1] « Identifier|Reference(MedicationOrder| VisionPrescription) »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription[x] : Type [0..1] « Identifier|Reference( MedicationOrder) »The referral resource which lists the date, practitioner, reason and other supporting informationreferral[x] : Type [0..1] « Identifier|Reference(ReferralRequest) »**Insert definition of Occurrence codesoccurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example)Example Occurrance ?? »**Insert definition of Occurrence Span codesoccurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example)Example Occurrance Span ?? »**Insert definition of Value codesvalueCode : Coding [0..*] « Value code (Strength=Example)Example Value ?? »List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationspecialCondition : Coding [0..*] « List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. (Strength=Example)Conditions ?? »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]Date of an accident which these services are addressingaccidentDate : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident PlaceaccidentLocation[x] : Type [0..1] « Address|Reference(Location) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example)Intervention ?? »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total cost of the services reportedtotalCost : Quantity(Money) [0..1]The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : Quantity(Money) [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)totalBenefit : Quantity(Money) [0..1]Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Quantity(Money) [0..1]Reason for the payment adjustmentpaymentAdjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datapaymentDate : date [0..1]Payable less any payment adjustmentpaymentAmount : Quantity(Money) [0..1]Payment identiferpaymentRef : Identifier [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »RelatedClaimsOther claims which are related to this claim such as prior claim versions or for related servicesclaim[x] : Type [0..1] « Identifier|Reference(Claim) »For example prior or umbrellarelationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example)ICD-10 ?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « Coding|Reference(Procedure); ICD10 Procedure codes (Strength=Example)ICD-10 Procedure ?? »CoverageReference to the program or plan identification, underwriter or payorcoverage[x] : Type [1..1] « Identifier|Reference(Coverage) »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]OnsetThe start or start and end dates for the treatable conditiontime[x] : Type [0..1] « date|Period »Onset typifications eg. Start of pregnancy, start of illnes, etctype : Coding [0..1] « Condition related start, end and period codes (Strength=Example)Example Onset Type (Reason) ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The practitioner who is supervising the work of the servicing provider(s)supervisor[x] : Type [0..1] « Identifier|Reference(Practitioner) »The qualification which is applicable for this serviceproviderQualification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Unusual circumstances which may influence adjudicationserviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example)Example Service Modifier ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedplace : Coding [0..1] « Place where the service is rendered (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »DetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The fee for an addittional service or product or chargeservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]A list of note references to the notes provided belownoteNumberLinkId : positiveInt [0..*]AddedItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]AddedItemDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]NotesAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]BenefitBalanceDental, Vision, Medical, Pharmacy, Rehab etccategory : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »Network designationnetwork : Coding [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|Quantity(Money) »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Quantity(Money) »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health carecoverage[1..1]Period, start and last dates of aspects of the Condition or related servicesonset[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The second tier service adjudications for payor added servicesdetail[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]Note textnote[0..*]Benefits Used to datefinancial[0..*]Balance by Benefit CategorybenefitBalance[0..*]

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>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider for the claim --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization for the claim --></organization[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>
 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <adjudication>  <!-- 0..* Detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <adjudication>  <!-- 0..* SubDetail adjudication -->
     <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
     <reason><!-- 0..1 Coding Adjudication reason --></reason>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  // claim[x]: Claim reference. One of these 2:
  "claimIdentifier" : { Identifier },
  "claimReference" : { Reference(Claim) },
  // claimResponse[x]: Claim response reference. One of these 2:
  "claimResponseIdentifier" : { Identifier },
  "claimResponseReference" : { Reference(ClaimResponse) },
  "subType" : [{ Coding }], // Finer grained claim type information
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission
  "disposition" : "<string>", // Disposition Message
  // provider[x]: Responsible provider for the claim. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization for the claim. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:
    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:
  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:
  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Payee
    "type" : { Coding }, // Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "coverage" : { // R!  Insurance or medical plan
    // coverage[x]: Insurance information. One of these 2:
    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:
  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:
    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:
    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:
    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "adjudication" : [{ // Detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "adjudication" : [{ // SubDetail adjudication
          "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "reason" : { Coding }, // Adjudication reason
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductable
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 2:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit ΣDomainResourceExplanation of Benefit resource
... identifier Σ0..*IdentifierBusiness Identifier
... claim[x] Σ0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] Σ0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... disposition Σ0..1stringDisposition Message
... provider[x] Σ0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence Σ0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage Σ1..1BackboneElementInsurance or medical plan
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..*Reference(Device)Unique Device Identifier
..... adjudication Σ0..*BackboneElementDetail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..*Reference(Device)Unique Device Identifier
...... adjudication Σ0..*BackboneElementSubDetail adjudication
....... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monitory value
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductable
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanitory text
... benefitBalance Σ0..*BackboneElementBalance by Benefit Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney

doco Documentation for this format

UML Diagram

ExplanationOfBenefit (DomainResource)The Response Business Identifieridentifier : Identifier [0..*]The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaim[x] : Type [0..1] « Identifier|Reference(Claim) »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaimResponse[x] : Type [0..1] « Identifier|Reference(ClaimResponse) »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : Coding [0..*] « A more granulat claim typecode (Strength=Example)Example Claim SubType ?? »The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the EOB was createdcreated : dateTime [0..1]The billable period for which charges are being submittedbillablePeriod : Period [0..1]A description of the status of the adjudicationdisposition : string [0..1]The provider which is responsible for the claimprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The provider which is responsible for the claimorganization[x] : Type [0..1] « Identifier|Reference(Organization) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Prescription to support the dispensing of Pharmacy or Vision productsprescription[x] : Type [0..1] « Identifier|Reference(MedicationOrder| VisionPrescription) »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription[x] : Type [0..1] « Identifier|Reference( MedicationOrder) »The referral resource which lists the date, practitioner, reason and other supporting informationreferral[x] : Type [0..1] « Identifier|Reference(ReferralRequest) »**Insert definition of Occurrence codesoccurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example)Example Occurrance ?? »**Insert definition of Occurrence Span codesoccurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example)Example Occurrance Span ?? »**Insert definition of Value codesvalueCode : Coding [0..*] « Value code (Strength=Example)Example Value ?? »List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationspecialCondition : Coding [0..*] « List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. (Strength=Example)Conditions ?? »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]Date of an accident which these services are addressingaccidentDate : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident PlaceaccidentLocation[x] : Type [0..1] « Address|Reference(Location) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example)Intervention ?? »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total cost of the services reportedtotalCost : Quantity(Money) [0..1]The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : Quantity(Money) [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)totalBenefit : Quantity(Money) [0..1]Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Quantity(Money) [0..1]Reason for the payment adjustmentpaymentAdjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datapaymentDate : date [0..1]Payable less any payment adjustmentpaymentAmount : Quantity(Money) [0..1]Payment identiferpaymentRef : Identifier [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »RelatedClaimsOther claims which are related to this claim such as prior claim versions or for related servicesclaim[x] : Type [0..1] « Identifier|Reference(Claim) »For example prior or umbrellarelationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example)ICD-10 ?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « Coding|Reference(Procedure); ICD10 Procedure codes (Strength=Example)ICD-10 Procedure ?? »CoverageReference to the program or plan identification, underwriter or payorcoverage[x] : Type [1..1] « Identifier|Reference(Coverage) »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]OnsetThe start or start and end dates for the treatable conditiontime[x] : Type [0..1] « date|Period »Onset typifications eg. Start of pregnancy, start of illnes, etctype : Coding [0..1] « Condition related start, end and period codes (Strength=Example)Example Onset Type (Reason) ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The practitioner who is supervising the work of the servicing provider(s)supervisor[x] : Type [0..1] « Identifier|Reference(Practitioner) »The qualification which is applicable for this serviceproviderQualification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Unusual circumstances which may influence adjudicationserviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example)Example Service Modifier ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedplace : Coding [0..1] « Place where the service is rendered (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »DetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The fee for an addittional service or product or chargeservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Quantity(Money) [0..1]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 amountfactor : decimal [0..1]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 pointpoints : decimal [0..1]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 suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]A list of note references to the notes provided belownoteNumberLinkId : positiveInt [0..*]AddedItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]AddedItemDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]NotesAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]BenefitBalanceDental, Vision, Medical, Pharmacy, Rehab etccategory : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »Network designationnetwork : Coding [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|Quantity(Money) »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Quantity(Money) »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health carecoverage[1..1]Period, start and last dates of aspects of the Condition or related servicesonset[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The second tier service adjudications for payor added servicesdetail[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]Note textnote[0..*]Benefits Used to datefinancial[0..*]Balance by Benefit CategorybenefitBalance[0..*]

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>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider for the claim --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization for the claim --></organization[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>
 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <adjudication>  <!-- 0..* Detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <adjudication>  <!-- 0..* SubDetail adjudication -->
     <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
     <reason><!-- 0..1 Coding Adjudication reason --></reason>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  // claim[x]: Claim reference. One of these 2:
  "claimIdentifier" : { Identifier },
  "claimReference" : { Reference(Claim) },
  // claimResponse[x]: Claim response reference. One of these 2:
  "claimResponseIdentifier" : { Identifier },
  "claimResponseReference" : { Reference(ClaimResponse) },
  "subType" : [{ Coding }], // Finer grained claim type information
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission
  "disposition" : "<string>", // Disposition Message
  // provider[x]: Responsible provider for the claim. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization for the claim. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:
    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:
  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:
  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Payee
    "type" : { Coding }, // Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "coverage" : { // R!  Insurance or medical plan
    // coverage[x]: Insurance information. One of these 2:
    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:
  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:
    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:
    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:
    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "adjudication" : [{ // Detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "adjudication" : [{ // SubDetail adjudication
          "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "reason" : { Coding }, // Adjudication reason
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductable
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 2:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }]
}

 

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

7.6.2.1 Terminology Bindings

PathDefinitionTypeReference
ExplanationOfBenefit.subType A more granulat claim typecodeExampleExample Claim SubType Codes
ExplanationOfBenefit.ruleset
ExplanationOfBenefit.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
ExplanationOfBenefit.related.relationship Relationship of this claim to a related ClaimExampleExample Related Claim Relationship Codes
ExplanationOfBenefit.payee.type A code for the party to be reimbursed.ExamplePayee Type Codes
ExplanationOfBenefit.occurrenceCode Occurrence codesExampleExample Occurrance Codes
ExplanationOfBenefit.occurenceSpanCode Occurrence Span codesExampleExample Occurrance Span Codes
ExplanationOfBenefit.valueCode Value codeExampleExample Value Codes
ExplanationOfBenefit.diagnosis.diagnosis ICD10 Diagnostic codesExampleICD-10 Codes
ExplanationOfBenefit.procedure.procedure[x] ICD10 Procedure codesExampleICD-10 Procedure Codes
ExplanationOfBenefit.specialCondition List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.ExampleConditions Codes
ExplanationOfBenefit.accidentType Type of accident: work place, auto, etc.RequiredActIncidentCode
ExplanationOfBenefit.interventionException Intervention and exception codes (Pharm)ExampleIntervention Codes
ExplanationOfBenefit.onset.type Condition related start, end and period codesExampleExample Onset Type (Reason) Codes
ExplanationOfBenefit.item.type
ExplanationOfBenefit.item.detail.type
ExplanationOfBenefit.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc.RequiredActInvoiceGroupCode
ExplanationOfBenefit.item.providerQualification Provider professional qualificationsExampleExample Provider Qualification Codes
ExplanationOfBenefit.item.service
ExplanationOfBenefit.item.detail.service
ExplanationOfBenefit.item.detail.subDetail.service
ExplanationOfBenefit.addItem.service
ExplanationOfBenefit.addItem.detail.service 		Allowable service and product codesExampleUSCLS Codes
ExplanationOfBenefit.item.serviceModifier Factors which may influce adjudication of servicesExampleExample Service Modifier Codes
ExplanationOfBenefit.item.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
ExplanationOfBenefit.item.programCode
ExplanationOfBenefit.item.detail.programCode
ExplanationOfBenefit.item.detail.subDetail.programCode 		Program specific reason codesExampleExample Program Reason Codes
ExplanationOfBenefit.item.place Place where the service is renderedExampleExample Service Place Codes
ExplanationOfBenefit.item.bodySite The code for the teeth, quadrant, sextant and archExampleOral Site Codes
ExplanationOfBenefit.item.subSite The code for the tooth surface and surface combinationsExampleSurface Codes
ExplanationOfBenefit.item.adjudication.category
ExplanationOfBenefit.item.detail.adjudication.category
ExplanationOfBenefit.item.detail.subDetail.adjudication.category
ExplanationOfBenefit.addItem.adjudication.category
ExplanationOfBenefit.addItem.detail.adjudication.category 		The adjudication codes.ExtensibleAdjudication Codes
ExplanationOfBenefit.item.adjudication.reason
ExplanationOfBenefit.item.detail.adjudication.reason
ExplanationOfBenefit.item.detail.subDetail.adjudication.reason
ExplanationOfBenefit.addItem.adjudication.reason
ExplanationOfBenefit.addItem.detail.adjudication.reason 		Adjudication reason codes.ExtensibleAdjudication Reason Codes
ExplanationOfBenefit.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral)ExampleOral Prostho Material type Codes
ExplanationOfBenefit.missingTeeth.tooth The codes for the teeth, subset of OralSitesExampleTeeth Codes
ExplanationOfBenefit.missingTeeth.reason Reason codes for the missing teethExampleMissing Tooth Reason Codes
ExplanationOfBenefit.paymentAdjustmentReason Payment Adjustment reason codes.ExtensiblePayment Adjustment Reason Codes
ExplanationOfBenefit.reserved For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
ExplanationOfBenefit.form The forms codes.RequiredForm Codes
ExplanationOfBenefit.note.type The presentation types of notes.RequiredNoteType
ExplanationOfBenefit.benefitBalance.category Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
ExplanationOfBenefit.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
ExplanationOfBenefit.benefitBalance.network Code to classify in or out of network servicesExampleNetwork Type Codes
ExplanationOfBenefit.benefitBalance.unit Unit covered/serviced - individual or familyExampleUnit Type Codes
ExplanationOfBenefit.benefitBalance.term Coverage unit - annual, lifetimeExampleBenefit Term Codes
ExplanationOfBenefit.benefitBalance.financial.type Deductable, visits, co-pay, etc.ExampleBenefit Type 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
claimindentifiertokenThe reference to the claimExplanationOfBenefit.claimIdentifier
claimreferencereferenceThe reference to the claimExplanationOfBenefit.claimReference
(Claim)
createddateThe creation date for the EOBExplanationOfBenefit.created
dispositionstringThe contents of the disposition messageExplanationOfBenefit.disposition
facilityidentifiertokenFacility responsible for the goods and servicesExplanationOfBenefit.facilityIdentifier
facilityreferencereferenceFacility responsible for the goods and servicesExplanationOfBenefit.facilityReference
(Location)
identifiertokenThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier
organizationidentifiertokenThe reference to the providing organizationExplanationOfBenefit.organizationIdentifier
organizationreferencereferenceThe reference to the providing organizationExplanationOfBenefit.organizationReference
(Organization)
patientidentifiertokenThe reference to the patientExplanationOfBenefit.patientIdentifier
patientreferencereferenceThe reference to the patientExplanationOfBenefit.patientReference
(Patient)
provideridentifiertokenThe reference to the providerExplanationOfBenefit.providerIdentifier
providerreferencereferenceThe reference to the providerExplanationOfBenefit.providerReference
(Practitioner)