STU 3 Ballot

This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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

13.6 Resource ExplanationOfBenefit - Content

Financial Management Work GroupMaturity Level: 1Compartments: 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.

13.6.1 Scope and Usage

Notice to ballotors: The name of this resource is referred to in regulations in some jurisdictions and therefor to reduce confusion or issues it may be appropriate to rename this resource, for example to ClaimSummary. Please advise the Financial Managemet Work Group if this is the case for your jurisdaiction and provide a new name recommendation.

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

13.6.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... author[x] 0..1Insurer
.... authorIdentifierIdentifier
.... authorReferenceReference(Organization)
... claim[x] 0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] 0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... type 1..1CodingType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... billablePeriod 0..1PeriodPeriod for charge submission
... outcome 0..1Codingcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... provider[x] 0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] 0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] 0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] 0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship 0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription[x] 0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] 0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee 0..1BackboneElementPayee
.... type 0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] 0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... information 0..*BackboneElement
.... category 1..1CodingCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodingType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data
..... valueStringstring
..... valueQuantityQuantity
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis 1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
.... type 0..*CodingType of Diagnosis
Example Diagnosis Type Codes (Example)
.... drg 0..1CodingDiagnosis Related Group
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... patient[x] 1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage 1..1BackboneElementInsurance or medical plan
.... coverage[x] 0..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElement
.... date 0..1dateWhen the accident occurred
.... type 0..1CodingThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeam 0..*BackboneElement
..... provider[x] 1..1
...... providerIdentifierIdentifier
...... providerReferenceReference(Practitioner | Organization)
..... responsible 0..1booleanBilling practitioner
..... role 0..1CodingRole on the team
Claim Care Team Role Codes (Example)
..... qualification 0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodingCoding
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... points 0..1decimalDifficulty scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodingService Location
Oral Site Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... points 0..1decimalDifficulty scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodingBilling Code
USCLS Codes (Example)
...... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... points 0..1decimalDifficulty scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubDetail adjudication
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... missingTeeth 0..*BackboneElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate of Extraction
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElement
.... type 0..1CodingPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... form 0..1CodingPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodingLanguage
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory 0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit
.... network 0..1CodingIn or out of network
Network Type Codes (Example)
.... unit 0..1CodingIndividual or family
Unit Type Codes (Example)
.... term 0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] 0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitStringstring
...... benefitMoneyMoney
..... benefitUsed[x] 0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedMoneyMoney

doco Documentation for this format

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)The EOB Business Identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)ExplanationOfBenefitStatus! »The insurer which is responsible for the explanation of benefitauthor[x] : Type [0..1] « Identifier|Reference(Organization) »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) »The category of claim, eg, oral, pharmacy, vision, insitutional, professionaltype : Coding [1..1] « The type or discipline-style of the claim (Strength=Required)Example Claim Type ! »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]Processing outcome errror, partial or complete processingoutcome : Coding [0..1] « The result of the claim processing (Strength=Example)Claim Processing ?? »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) »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]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 : Money [0..1]The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : 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 : Money [0..1]The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »RelatedClaimOther 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 ?? »organization | patient | practitioner | relatedpersonresourceType : Coding [0..1] « The type of payee Resource (Strength=Required)PayeeResourceType! »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »SpecialConditionThe general class of the information supplied: information; exception; accident, employment; onset, etccategory : Coding [1..1] « The valuset used for additional information category codes. (Strength=Example)Claim Information Category ?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : Coding [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional datavalue[x] : Type [0..1] « string|Quantity »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 ?? »The type of the Diagnosis, for example: admitting,type : Coding [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example)Example Diagnosis Type ?? »The Diagnosis Related Group (DRG) code based on the assigned grouping code systemdrg : Coding [0..1] « The DRG codes associated with the diagnosis (Strength=Example)Example Diagnosis Related Gro...?? »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 [0..1] « Identifier|Reference(Coverage) »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]AccidentDate of an accident which these services are addressingdate : date [0..1]Type of accident: work, auto, etctype : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Where the accident occurredlocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 providedlocation[x] : Type [0..1] « Coding|Address|Reference(Location); 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 : 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 : 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..*]CareTeamThe members of the team who provided the overall serviceprovider[x] : Type [1..1] « Identifier|Reference(Practitioner| Organization) »The practitioner who is billing and responsible for the claimed services rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : Coding [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »AdjudicationCode 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 : 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! »The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 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 : 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 : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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 type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : 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 : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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..*]The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemsDetailThe type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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]PaymentWhether this represents partial or complete payment of the claimtype : Coding [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datedate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identiferidentifier : Identifier [0..1]NoteAn 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]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : Coding [0..1] « A human language. (Strength=Extensible)Common Languages+ »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 ?? »A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]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|string|Money »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|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]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]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]An accident which resulted in the need for healthcare servicesaccident[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[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..*]Payment details for the claim if the claim has been paidpayment[0..1]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>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <author[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></author[x]>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <type><!-- 1..1 Coding Type or discipline --></type>
 <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>
 <outcome><!-- 0..1 Coding complete | error | partial --></outcome>
 <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>
  <resourceType><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resourceType>
  <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]>
 <information>  <!-- 0..* -->
  <category><!-- 1..1 Coding Category of information --></category>
  <code><!-- 0..1 Coding Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity Additional Data --></value[x]>
 </information>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
  <type><!-- 0..* Coding Type of Diagnosis --></type>
  <drg><!-- 0..1 Coding Diagnosis Related Group --></drg>
 </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>
 <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]><!-- 0..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accident> 
  <date value="[date]"/><!-- 0..1 When the accident occurred -->
  <type><!-- 0..1 Coding The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <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 -->
  <careTeam>  <!-- 0..* -->
   <provider[x]><!-- 1..1 Identifier|Reference(Practitioner|Organization)  --></provider[x]>
   <responsible value="[boolean]"/><!-- 0..1 Billing practitioner -->
   <role><!-- 0..1 Coding Role on the team --></role>
   <qualification><!-- 0..1 Coding Type, classification or Specialization --></qualification>
  </careTeam>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
  <category><!-- 0..1 Coding Type of service or product --></category>
  <service><!-- 0..1 Coding Billing Code --></service>
  <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]>
  <location[x]><!-- 0..1 Coding|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 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 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 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>
   <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
   <category><!-- 0..1 Coding Type of service or product --></category>
   <service><!-- 0..1 Coding Billing Code --></service>
   <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 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 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
    <category><!-- 0..1 Coding Type of service or product --></category>
    <service><!-- 0..1 Coding Billing Code --></service>
    <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 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 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication SubDetail adjudication --></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 -->
  <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
  <category><!-- 0..1 Coding Type of service or product --></category>
  <service><!-- 0..1 Coding Billing Code --></service>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
   <category><!-- 0..1 Coding Type of service or product --></category>
   <service><!-- 0..1 Coding Billing Code --></service>
   <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items detail adjudication --></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 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment> 
  <type><!-- 0..1 Coding Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <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 -->
  <language><!-- 0..1 Coding Language --></language>
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <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|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|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
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // author[x]: Insurer. One of these 2:
  "authorIdentifier" : { Identifier },
  "authorReference" : { Reference(Organization) },
  // 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) },
  "type" : { Coding }, // R!  Type or discipline
  "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
  "outcome" : { Coding }, // complete | error | partial
  "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
    "resourceType" : { Coding }, // organization | patient | practitioner | relatedperson
    // 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) },
  "information" : [{ // 
    "category" : { Coding }, // R!  Category of information
    "code" : { Coding }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data. One of these 2:
    "valueString" : "<string>"
    "valueQuantity" : { Quantity }
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding }, // R!  Patient's list of diagnosis
    "type" : [{ Coding }], // Type of Diagnosis
    "drg" : { Coding } // Diagnosis Related Group
  }],
  "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) }
  }],
  // 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
  },
  "accident" : { // 
    "date" : "<date>", // When the accident occurred
    "type" : { Coding }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeam" : [{ // 
      // provider[x]: . One of these 2:
      "providerIdentifier" : { Identifier },
      "providerReference" : { Reference(Practitioner|Organization) },
      "responsible" : <boolean>, // Billing practitioner
      "role" : { Coding }, // Role on the team
      "qualification" : { Coding } // Type, classification or Specialization
    }],
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "revenue" : { Coding }, // Revenue or cost center code
    "category" : { Coding }, // Type of service or product
    "service" : { Coding }, // Billing Code
    "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 },
    // location[x]: Place of service. One of these 3:
    "locationCoding" : { Coding },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { 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" : { 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
      "revenue" : { Coding }, // Revenue or cost center code
      "category" : { Coding }, // Type of service or product
      "service" : { Coding }, // Billing Code
      "modifier" : [{ Coding }], // Service/Product billing modifiers
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "revenue" : { Coding }, // Revenue or cost center code
        "category" : { Coding }, // Type of service or product
        "service" : { Coding }, // Billing Code
        "modifier" : [{ Coding }], // Service/Product billing modifiers
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // SubDetail adjudication
      }]
    }],
    "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
    "revenue" : { Coding }, // Revenue or cost center code
    "category" : { Coding }, // Type of service or product
    "service" : { Coding }, // Billing Code
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { Coding }, // Revenue or cost center code
      "category" : { Coding }, // Type of service or product
      "service" : { Coding }, // Billing Code
      "modifier" : [{ Coding }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // 
    "type" : { Coding }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { Coding }, // Reason for Payment adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "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
    "language" : { Coding } // Language
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "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 3:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:ExplanationOfBenefit.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # ExplanationOfBenefit.author[x] : 0..1 Insurer. One of these 2
    fhir:ExplanationOfBenefit.authorIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.authorReference [ Reference(Organization) ]
  # ExplanationOfBenefit.claim[x] : 0..1 Claim reference. One of these 2
    fhir:ExplanationOfBenefit.claimIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.claimReference [ Reference(Claim) ]
  # ExplanationOfBenefit.claimResponse[x] : 0..1 Claim response reference. One of these 2
    fhir:ExplanationOfBenefit.claimResponseIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.claimResponseReference [ Reference(ClaimResponse) ]
  fhir:ExplanationOfBenefit.type [ Coding ]; # 1..1 Type or discipline
  fhir:ExplanationOfBenefit.subType [ Coding ], ... ; # 0..* Finer grained claim type information
  fhir:ExplanationOfBenefit.ruleset [ Coding ]; # 0..1 Current specification followed
  fhir:ExplanationOfBenefit.originalRuleset [ Coding ]; # 0..1 Original specification followed
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:ExplanationOfBenefit.outcome [ Coding ]; # 0..1 complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  # ExplanationOfBenefit.provider[x] : 0..1 Responsible provider for the claim. One of these 2
    fhir:ExplanationOfBenefit.providerIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.providerReference [ Reference(Practitioner) ]
  # ExplanationOfBenefit.organization[x] : 0..1 Responsible organization for the claim. One of these 2
    fhir:ExplanationOfBenefit.organizationIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.organizationReference [ Reference(Organization) ]
  # ExplanationOfBenefit.facility[x] : 0..1 Servicing Facility. One of these 2
    fhir:ExplanationOfBenefit.facilityIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.facilityReference [ Reference(Location) ]
  fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claimn
    # ExplanationOfBenefit.related.claim[x] : 0..1 Reference to the related claim. One of these 2
      fhir:ExplanationOfBenefit.related.claimIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.related.claimReference [ Reference(Claim) ]
    fhir:ExplanationOfBenefit.related.relationship [ Coding ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  # ExplanationOfBenefit.prescription[x] : 0..1 Prescription. One of these 2
    fhir:ExplanationOfBenefit.prescriptionIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.prescriptionReference [ Reference(MedicationOrder|VisionPrescription) ]
  # ExplanationOfBenefit.originalPrescription[x] : 0..1 Original Prescription. One of these 2
    fhir:ExplanationOfBenefit.originalPrescriptionIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.originalPrescriptionReference [ Reference(MedicationOrder) ]
  fhir:ExplanationOfBenefit.payee [ # 0..1 Payee
    fhir:ExplanationOfBenefit.payee.type [ Coding ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    # ExplanationOfBenefit.payee.party[x] : 0..1 Party to receive the payable. One of these 2
      fhir:ExplanationOfBenefit.payee.partyIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.payee.partyReference [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]
  ];
  # ExplanationOfBenefit.referral[x] : 0..1 Treatment Referral. One of these 2
    fhir:ExplanationOfBenefit.referralIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.referralReference [ Reference(ReferralRequest) ]
  fhir:ExplanationOfBenefit.information [ # 0..* 
    fhir:ExplanationOfBenefit.information.category [ Coding ]; # 1..1 Category of information
    fhir:ExplanationOfBenefit.information.code [ Coding ]; # 0..1 Type of information
    # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.information.timingDate [ date ]
      fhir:ExplanationOfBenefit.information.timingPeriod [ Period ]
    # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data. One of these 2
      fhir:ExplanationOfBenefit.information.valueString [ string ]
      fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ]
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    fhir:ExplanationOfBenefit.diagnosis.diagnosis [ Coding ]; # 1..1 Patient's list of diagnosis
    fhir:ExplanationOfBenefit.diagnosis.type [ Coding ], ... ; # 0..* Type of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.drg [ Coding ]; # 0..1 Diagnosis Related Group
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCoding [ Coding ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  # ExplanationOfBenefit.patient[x] : 1..1 The subject of the Products and Services. One of these 2
    fhir:ExplanationOfBenefit.patientIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.patientReference [ Reference(Patient) ]
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.coverage [ # 1..1 Insurance or medical plan
    # ExplanationOfBenefit.coverage.coverage[x] : 0..1 Insurance information. One of these 2
      fhir:ExplanationOfBenefit.coverage.coverageIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.coverage.coverageReference [ Reference(Coverage) ]
    fhir:ExplanationOfBenefit.coverage.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
  ];
  fhir:ExplanationOfBenefit.accident [ # 0..1 
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred
    fhir:ExplanationOfBenefit.accident.type [ Coding ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:ExplanationOfBenefit.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:ExplanationOfBenefit.item.careTeam [ # 0..* 
      # ExplanationOfBenefit.item.careTeam.provider[x] : 1..1 . One of these 2
        fhir:ExplanationOfBenefit.item.careTeam.providerIdentifier [ Identifier ]
        fhir:ExplanationOfBenefit.item.careTeam.providerReference [ Reference(Practitioner|Organization) ]
      fhir:ExplanationOfBenefit.item.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner
      fhir:ExplanationOfBenefit.item.careTeam.role [ Coding ]; # 0..1 Role on the team
      fhir:ExplanationOfBenefit.item.careTeam.qualification [ Coding ]; # 0..1 Type, classification or Specialization
    ], ...;
    fhir:ExplanationOfBenefit.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.revenue [ Coding ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ Coding ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.item.service [ Coding ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.item.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. One of these 3
      fhir:ExplanationOfBenefit.item.locationCoding [ Coding ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.points [ decimal ]; # 0..1 Difficulty scaling factor
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:ExplanationOfBenefit.item.bodySite [ Coding ]; # 0..1 Service Location
    fhir:ExplanationOfBenefit.item.subSite [ Coding ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ Coding ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ExplanationOfBenefit.item.adjudication.reason [ Coding ]; # 0..1 Adjudication reason
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitory value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:ExplanationOfBenefit.item.detail.type [ Coding ]; # 1..1 Group or type of product or service
      fhir:ExplanationOfBenefit.item.detail.revenue [ Coding ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ Coding ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.item.detail.service [ Coding ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.item.detail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
      fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.points [ decimal ]; # 0..1 Difficulty scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:ExplanationOfBenefit.item.detail.subDetail.type [ Coding ]; # 1..1 Type of product or service
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ Coding ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ Coding ]; # 0..1 Type of service or product
        fhir:ExplanationOfBenefit.item.detail.subDetail.service [ Coding ]; # 0..1 Billing Code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
        fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.points [ decimal ]; # 0..1 Difficulty scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* SubDetail adjudication
      ], ...;
    ], ...;
    fhir:ExplanationOfBenefit.item.prosthesis [ # 0..1 Prosthetic details
      fhir:ExplanationOfBenefit.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:ExplanationOfBenefit.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:ExplanationOfBenefit.item.prosthesis.priorMaterial [ Coding ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ExplanationOfBenefit.addItem.revenue [ Coding ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.category [ Coding ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.addItem.service [ Coding ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.addItem.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Added items details
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ Coding ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.category [ Coding ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.addItem.detail.service [ Coding ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.missingTeeth [ # 0..* Only if type = oral
    fhir:ExplanationOfBenefit.missingTeeth.tooth [ Coding ]; # 1..1 Tooth Code
    fhir:ExplanationOfBenefit.missingTeeth.reason [ Coding ]; # 0..1 Reason for missing
    fhir:ExplanationOfBenefit.missingTeeth.extractionDate [ date ]; # 0..1 Date of Extraction
  ], ...;
  fhir:ExplanationOfBenefit.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ExplanationOfBenefit.unallocDeductable [ Money ]; # 0..1 Unallocated deductable
  fhir:ExplanationOfBenefit.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ExplanationOfBenefit.payment [ # 0..1 
    fhir:ExplanationOfBenefit.payment.type [ Coding ]; # 0..1 Partial or Complete
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ Coding ]; # 0..1 Reason for Payment adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ExplanationOfBenefit.form [ Coding ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.note [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ExplanationOfBenefit.note.type [ Coding ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.note.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.note.language [ Coding ]; # 0..1 Language
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ Coding ]; # 1..1 Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ Coding ]; # 0..1 Benefit SubCategory
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:ExplanationOfBenefit.benefitBalance.network [ Coding ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ Coding ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ Coding ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ Coding ]; # 1..1 Deductable, visits, benefit amount
      # ExplanationOfBenefit.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since DSTU2

ExplanationOfBenefit
ExplanationOfBenefit.status added
ExplanationOfBenefit.author[x] added
ExplanationOfBenefit.claim[x] added
ExplanationOfBenefit.claimResponse[x] added
ExplanationOfBenefit.type added
ExplanationOfBenefit.subType added
ExplanationOfBenefit.billablePeriod added
ExplanationOfBenefit.outcome Type changed from code to Coding
Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.provider[x] added
ExplanationOfBenefit.organization[x] Renamed from organization to organization[x]
Add Identifier
ExplanationOfBenefit.facility[x] added
ExplanationOfBenefit.related added
ExplanationOfBenefit.related.claim[x] added
ExplanationOfBenefit.related.relationship added
ExplanationOfBenefit.related.reference added
ExplanationOfBenefit.prescription[x] added
ExplanationOfBenefit.originalPrescription[x] added
ExplanationOfBenefit.payee added
ExplanationOfBenefit.payee.type added
ExplanationOfBenefit.payee.resourceType added
ExplanationOfBenefit.payee.party[x] added
ExplanationOfBenefit.referral[x] added
ExplanationOfBenefit.information added
ExplanationOfBenefit.information.category added
ExplanationOfBenefit.information.code added
ExplanationOfBenefit.information.timing[x] added
ExplanationOfBenefit.information.value[x] added
ExplanationOfBenefit.diagnosis added
ExplanationOfBenefit.diagnosis.sequence added
ExplanationOfBenefit.diagnosis.diagnosis added
ExplanationOfBenefit.diagnosis.type added
ExplanationOfBenefit.diagnosis.drg added
ExplanationOfBenefit.procedure added
ExplanationOfBenefit.procedure.sequence added
ExplanationOfBenefit.procedure.date added
ExplanationOfBenefit.procedure.procedure[x] added
ExplanationOfBenefit.patient[x] added
ExplanationOfBenefit.precedence added
ExplanationOfBenefit.coverage added
ExplanationOfBenefit.coverage.coverage[x] added
ExplanationOfBenefit.coverage.preAuthRef added
ExplanationOfBenefit.accident added
ExplanationOfBenefit.accident.date added
ExplanationOfBenefit.accident.type added
ExplanationOfBenefit.accident.location[x] added
ExplanationOfBenefit.employmentImpacted added
ExplanationOfBenefit.hospitalization added
ExplanationOfBenefit.item added
ExplanationOfBenefit.item.sequence added
ExplanationOfBenefit.item.careTeam added
ExplanationOfBenefit.item.careTeam.provider[x] added
ExplanationOfBenefit.item.careTeam.responsible added
ExplanationOfBenefit.item.careTeam.role added
ExplanationOfBenefit.item.careTeam.qualification added
ExplanationOfBenefit.item.diagnosisLinkId added
ExplanationOfBenefit.item.revenue added
ExplanationOfBenefit.item.category added
ExplanationOfBenefit.item.service added
ExplanationOfBenefit.item.modifier added
ExplanationOfBenefit.item.programCode added
ExplanationOfBenefit.item.serviced[x] added
ExplanationOfBenefit.item.location[x] added
ExplanationOfBenefit.item.quantity added
ExplanationOfBenefit.item.unitPrice added
ExplanationOfBenefit.item.factor added
ExplanationOfBenefit.item.points added
ExplanationOfBenefit.item.net added
ExplanationOfBenefit.item.udi added
ExplanationOfBenefit.item.bodySite added
ExplanationOfBenefit.item.subSite added
ExplanationOfBenefit.item.noteNumber added
ExplanationOfBenefit.item.adjudication added
ExplanationOfBenefit.item.adjudication.category added
ExplanationOfBenefit.item.adjudication.reason added
ExplanationOfBenefit.item.adjudication.amount added
ExplanationOfBenefit.item.adjudication.value added
ExplanationOfBenefit.item.detail added
ExplanationOfBenefit.item.detail.sequence added
ExplanationOfBenefit.item.detail.type added
ExplanationOfBenefit.item.detail.revenue added
ExplanationOfBenefit.item.detail.category added
ExplanationOfBenefit.item.detail.service added
ExplanationOfBenefit.item.detail.modifier added
ExplanationOfBenefit.item.detail.programCode added
ExplanationOfBenefit.item.detail.quantity added
ExplanationOfBenefit.item.detail.unitPrice added
ExplanationOfBenefit.item.detail.factor added
ExplanationOfBenefit.item.detail.points added
ExplanationOfBenefit.item.detail.net added
ExplanationOfBenefit.item.detail.udi added
ExplanationOfBenefit.item.detail.noteNumber added
ExplanationOfBenefit.item.detail.adjudication added
ExplanationOfBenefit.item.detail.subDetail added
ExplanationOfBenefit.item.detail.subDetail.sequence added
ExplanationOfBenefit.item.detail.subDetail.type added
ExplanationOfBenefit.item.detail.subDetail.revenue added
ExplanationOfBenefit.item.detail.subDetail.category added
ExplanationOfBenefit.item.detail.subDetail.service added
ExplanationOfBenefit.item.detail.subDetail.modifier added
ExplanationOfBenefit.item.detail.subDetail.programCode added
ExplanationOfBenefit.item.detail.subDetail.quantity added
ExplanationOfBenefit.item.detail.subDetail.unitPrice added
ExplanationOfBenefit.item.detail.subDetail.factor added
ExplanationOfBenefit.item.detail.subDetail.points added
ExplanationOfBenefit.item.detail.subDetail.net added
ExplanationOfBenefit.item.detail.subDetail.udi added
ExplanationOfBenefit.item.detail.subDetail.noteNumber added
ExplanationOfBenefit.item.detail.subDetail.adjudication added
ExplanationOfBenefit.item.prosthesis added
ExplanationOfBenefit.item.prosthesis.initial added
ExplanationOfBenefit.item.prosthesis.priorDate added
ExplanationOfBenefit.item.prosthesis.priorMaterial added
ExplanationOfBenefit.addItem added
ExplanationOfBenefit.addItem.sequenceLinkId added
ExplanationOfBenefit.addItem.revenue added
ExplanationOfBenefit.addItem.category added
ExplanationOfBenefit.addItem.service added
ExplanationOfBenefit.addItem.modifier added
ExplanationOfBenefit.addItem.fee added
ExplanationOfBenefit.addItem.noteNumber added
ExplanationOfBenefit.addItem.adjudication added
ExplanationOfBenefit.addItem.detail added
ExplanationOfBenefit.addItem.detail.revenue added
ExplanationOfBenefit.addItem.detail.category added
ExplanationOfBenefit.addItem.detail.service added
ExplanationOfBenefit.addItem.detail.modifier added
ExplanationOfBenefit.addItem.detail.fee added
ExplanationOfBenefit.addItem.detail.noteNumber added
ExplanationOfBenefit.addItem.detail.adjudication added
ExplanationOfBenefit.missingTeeth added
ExplanationOfBenefit.missingTeeth.tooth added
ExplanationOfBenefit.missingTeeth.reason added
ExplanationOfBenefit.missingTeeth.extractionDate added
ExplanationOfBenefit.totalCost added
ExplanationOfBenefit.unallocDeductable added
ExplanationOfBenefit.totalBenefit added
ExplanationOfBenefit.payment added
ExplanationOfBenefit.payment.type added
ExplanationOfBenefit.payment.adjustment added
ExplanationOfBenefit.payment.adjustmentReason added
ExplanationOfBenefit.payment.date added
ExplanationOfBenefit.payment.amount added
ExplanationOfBenefit.payment.identifier added
ExplanationOfBenefit.form added
ExplanationOfBenefit.note added
ExplanationOfBenefit.note.number added
ExplanationOfBenefit.note.type added
ExplanationOfBenefit.note.text added
ExplanationOfBenefit.note.language added
ExplanationOfBenefit.benefitBalance added
ExplanationOfBenefit.benefitBalance.category added
ExplanationOfBenefit.benefitBalance.subCategory added
ExplanationOfBenefit.benefitBalance.name added
ExplanationOfBenefit.benefitBalance.description added
ExplanationOfBenefit.benefitBalance.network added
ExplanationOfBenefit.benefitBalance.unit added
ExplanationOfBenefit.benefitBalance.term added
ExplanationOfBenefit.benefitBalance.financial added
ExplanationOfBenefit.benefitBalance.financial.type added
ExplanationOfBenefit.benefitBalance.financial.benefit[x] added
ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] added
ExplanationOfBenefit.request deleted
ExplanationOfBenefit.requestProvider deleted
ExplanationOfBenefit.requestOrganization deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... author[x] 0..1Insurer
.... authorIdentifierIdentifier
.... authorReferenceReference(Organization)
... claim[x] 0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] 0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... type 1..1CodingType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... billablePeriod 0..1PeriodPeriod for charge submission
... outcome 0..1Codingcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... provider[x] 0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] 0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] 0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] 0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship 0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription[x] 0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] 0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee 0..1BackboneElementPayee
.... type 0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] 0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... information 0..*BackboneElement
.... category 1..1CodingCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodingType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data
..... valueStringstring
..... valueQuantityQuantity
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis 1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
.... type 0..*CodingType of Diagnosis
Example Diagnosis Type Codes (Example)
.... drg 0..1CodingDiagnosis Related Group
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... patient[x] 1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage 1..1BackboneElementInsurance or medical plan
.... coverage[x] 0..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElement
.... date 0..1dateWhen the accident occurred
.... type 0..1CodingThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeam 0..*BackboneElement
..... provider[x] 1..1
...... providerIdentifierIdentifier
...... providerReferenceReference(Practitioner | Organization)
..... responsible 0..1booleanBilling practitioner
..... role 0..1CodingRole on the team
Claim Care Team Role Codes (Example)
..... qualification 0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodingCoding
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... points 0..1decimalDifficulty scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodingService Location
Oral Site Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... points 0..1decimalDifficulty scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodingBilling Code
USCLS Codes (Example)
...... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... points 0..1decimalDifficulty scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubDetail adjudication
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... missingTeeth 0..*BackboneElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate of Extraction
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElement
.... type 0..1CodingPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... form 0..1CodingPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodingLanguage
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory 0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit
.... network 0..1CodingIn or out of network
Network Type Codes (Example)
.... unit 0..1CodingIndividual or family
Unit Type Codes (Example)
.... term 0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] 0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitStringstring
...... benefitMoneyMoney
..... benefitUsed[x] 0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedMoneyMoney

doco Documentation for this format

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)The EOB Business Identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)ExplanationOfBenefitStatus! »The insurer which is responsible for the explanation of benefitauthor[x] : Type [0..1] « Identifier|Reference(Organization) »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) »The category of claim, eg, oral, pharmacy, vision, insitutional, professionaltype : Coding [1..1] « The type or discipline-style of the claim (Strength=Required)Example Claim Type ! »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]Processing outcome errror, partial or complete processingoutcome : Coding [0..1] « The result of the claim processing (Strength=Example)Claim Processing ?? »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) »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]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 : Money [0..1]The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : 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 : Money [0..1]The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »RelatedClaimOther 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 ?? »organization | patient | practitioner | relatedpersonresourceType : Coding [0..1] « The type of payee Resource (Strength=Required)PayeeResourceType! »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »SpecialConditionThe general class of the information supplied: information; exception; accident, employment; onset, etccategory : Coding [1..1] « The valuset used for additional information category codes. (Strength=Example)Claim Information Category ?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : Coding [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional datavalue[x] : Type [0..1] « string|Quantity »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 ?? »The type of the Diagnosis, for example: admitting,type : Coding [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example)Example Diagnosis Type ?? »The Diagnosis Related Group (DRG) code based on the assigned grouping code systemdrg : Coding [0..1] « The DRG codes associated with the diagnosis (Strength=Example)Example Diagnosis Related Gro...?? »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 [0..1] « Identifier|Reference(Coverage) »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]AccidentDate of an accident which these services are addressingdate : date [0..1]Type of accident: work, auto, etctype : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Where the accident occurredlocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 providedlocation[x] : Type [0..1] « Coding|Address|Reference(Location); 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 : 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 : 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..*]CareTeamThe members of the team who provided the overall serviceprovider[x] : Type [1..1] « Identifier|Reference(Practitioner| Organization) »The practitioner who is billing and responsible for the claimed services rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : Coding [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »AdjudicationCode 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 : 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! »The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 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 : 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 : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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 type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : 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 : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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..*]The type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemsDetailThe type of reveneu or cost center providing the product and/or servicerevenue : Coding [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : Coding [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : 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 ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]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]PaymentWhether this represents partial or complete payment of the claimtype : Coding [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datedate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identiferidentifier : Identifier [0..1]NoteAn 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]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : Coding [0..1] « A human language. (Strength=Extensible)Common Languages+ »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 ?? »A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]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|string|Money »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|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]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]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]An accident which resulted in the need for healthcare servicesaccident[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[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..*]Payment details for the claim if the claim has been paidpayment[0..1]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>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <author[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></author[x]>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <type><!-- 1..1 Coding Type or discipline --></type>
 <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>
 <outcome><!-- 0..1 Coding complete | error | partial --></outcome>
 <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>
  <resourceType><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resourceType>
  <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]>
 <information>  <!-- 0..* -->
  <category><!-- 1..1 Coding Category of information --></category>
  <code><!-- 0..1 Coding Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity Additional Data --></value[x]>
 </information>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
  <type><!-- 0..* Coding Type of Diagnosis --></type>
  <drg><!-- 0..1 Coding Diagnosis Related Group --></drg>
 </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>
 <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]><!-- 0..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accident> 
  <date value="[date]"/><!-- 0..1 When the accident occurred -->
  <type><!-- 0..1 Coding The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <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 -->
  <careTeam>  <!-- 0..* -->
   <provider[x]><!-- 1..1 Identifier|Reference(Practitioner|Organization)  --></provider[x]>
   <responsible value="[boolean]"/><!-- 0..1 Billing practitioner -->
   <role><!-- 0..1 Coding Role on the team --></role>
   <qualification><!-- 0..1 Coding Type, classification or Specialization --></qualification>
  </careTeam>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
  <category><!-- 0..1 Coding Type of service or product --></category>
  <service><!-- 0..1 Coding Billing Code --></service>
  <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]>
  <location[x]><!-- 0..1 Coding|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 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 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 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>
   <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
   <category><!-- 0..1 Coding Type of service or product --></category>
   <service><!-- 0..1 Coding Billing Code --></service>
   <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 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 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
    <category><!-- 0..1 Coding Type of service or product --></category>
    <service><!-- 0..1 Coding Billing Code --></service>
    <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 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 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication SubDetail adjudication --></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 -->
  <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
  <category><!-- 0..1 Coding Type of service or product --></category>
  <service><!-- 0..1 Coding Billing Code --></service>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 Coding Revenue or cost center code --></revenue>
   <category><!-- 0..1 Coding Type of service or product --></category>
   <service><!-- 0..1 Coding Billing Code --></service>
   <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items detail adjudication --></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 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment> 
  <type><!-- 0..1 Coding Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <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 -->
  <language><!-- 0..1 Coding Language --></language>
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <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|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|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
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // author[x]: Insurer. One of these 2:
  "authorIdentifier" : { Identifier },
  "authorReference" : { Reference(Organization) },
  // 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) },
  "type" : { Coding }, // R!  Type or discipline
  "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
  "outcome" : { Coding }, // complete | error | partial
  "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
    "resourceType" : { Coding }, // organization | patient | practitioner | relatedperson
    // 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) },
  "information" : [{ // 
    "category" : { Coding }, // R!  Category of information
    "code" : { Coding }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data. One of these 2:
    "valueString" : "<string>"
    "valueQuantity" : { Quantity }
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding }, // R!  Patient's list of diagnosis
    "type" : [{ Coding }], // Type of Diagnosis
    "drg" : { Coding } // Diagnosis Related Group
  }],
  "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) }
  }],
  // 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
  },
  "accident" : { // 
    "date" : "<date>", // When the accident occurred
    "type" : { Coding }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeam" : [{ // 
      // provider[x]: . One of these 2:
      "providerIdentifier" : { Identifier },
      "providerReference" : { Reference(Practitioner|Organization) },
      "responsible" : <boolean>, // Billing practitioner
      "role" : { Coding }, // Role on the team
      "qualification" : { Coding } // Type, classification or Specialization
    }],
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "revenue" : { Coding }, // Revenue or cost center code
    "category" : { Coding }, // Type of service or product
    "service" : { Coding }, // Billing Code
    "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 },
    // location[x]: Place of service. One of these 3:
    "locationCoding" : { Coding },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { 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" : { 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
      "revenue" : { Coding }, // Revenue or cost center code
      "category" : { Coding }, // Type of service or product
      "service" : { Coding }, // Billing Code
      "modifier" : [{ Coding }], // Service/Product billing modifiers
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "revenue" : { Coding }, // Revenue or cost center code
        "category" : { Coding }, // Type of service or product
        "service" : { Coding }, // Billing Code
        "modifier" : [{ Coding }], // Service/Product billing modifiers
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // SubDetail adjudication
      }]
    }],
    "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
    "revenue" : { Coding }, // Revenue or cost center code
    "category" : { Coding }, // Type of service or product
    "service" : { Coding }, // Billing Code
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { Coding }, // Revenue or cost center code
      "category" : { Coding }, // Type of service or product
      "service" : { Coding }, // Billing Code
      "modifier" : [{ Coding }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // 
    "type" : { Coding }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { Coding }, // Reason for Payment adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "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
    "language" : { Coding } // Language
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "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 3:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:ExplanationOfBenefit.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # ExplanationOfBenefit.author[x] : 0..1 Insurer. One of these 2
    fhir:ExplanationOfBenefit.authorIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.authorReference [ Reference(Organization) ]
  # ExplanationOfBenefit.claim[x] : 0..1 Claim reference. One of these 2
    fhir:ExplanationOfBenefit.claimIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.claimReference [ Reference(Claim) ]
  # ExplanationOfBenefit.claimResponse[x] : 0..1 Claim response reference. One of these 2
    fhir:ExplanationOfBenefit.claimResponseIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.claimResponseReference [ Reference(ClaimResponse) ]
  fhir:ExplanationOfBenefit.type [ Coding ]; # 1..1 Type or discipline
  fhir:ExplanationOfBenefit.subType [ Coding ], ... ; # 0..* Finer grained claim type information
  fhir:ExplanationOfBenefit.ruleset [ Coding ]; # 0..1 Current specification followed
  fhir:ExplanationOfBenefit.originalRuleset [ Coding ]; # 0..1 Original specification followed
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:ExplanationOfBenefit.outcome [ Coding ]; # 0..1 complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  # ExplanationOfBenefit.provider[x] : 0..1 Responsible provider for the claim. One of these 2
    fhir:ExplanationOfBenefit.providerIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.providerReference [ Reference(Practitioner) ]
  # ExplanationOfBenefit.organization[x] : 0..1 Responsible organization for the claim. One of these 2
    fhir:ExplanationOfBenefit.organizationIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.organizationReference [ Reference(Organization) ]
  # ExplanationOfBenefit.facility[x] : 0..1 Servicing Facility. One of these 2
    fhir:ExplanationOfBenefit.facilityIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.facilityReference [ Reference(Location) ]
  fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claimn
    # ExplanationOfBenefit.related.claim[x] : 0..1 Reference to the related claim. One of these 2
      fhir:ExplanationOfBenefit.related.claimIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.related.claimReference [ Reference(Claim) ]
    fhir:ExplanationOfBenefit.related.relationship [ Coding ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  # ExplanationOfBenefit.prescription[x] : 0..1 Prescription. One of these 2
    fhir:ExplanationOfBenefit.prescriptionIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.prescriptionReference [ Reference(MedicationOrder|VisionPrescription) ]
  # ExplanationOfBenefit.originalPrescription[x] : 0..1 Original Prescription. One of these 2
    fhir:ExplanationOfBenefit.originalPrescriptionIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.originalPrescriptionReference [ Reference(MedicationOrder) ]
  fhir:ExplanationOfBenefit.payee [ # 0..1 Payee
    fhir:ExplanationOfBenefit.payee.type [ Coding ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    # ExplanationOfBenefit.payee.party[x] : 0..1 Party to receive the payable. One of these 2
      fhir:ExplanationOfBenefit.payee.partyIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.payee.partyReference [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]
  ];
  # ExplanationOfBenefit.referral[x] : 0..1 Treatment Referral. One of these 2
    fhir:ExplanationOfBenefit.referralIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.referralReference [ Reference(ReferralRequest) ]
  fhir:ExplanationOfBenefit.information [ # 0..* 
    fhir:ExplanationOfBenefit.information.category [ Coding ]; # 1..1 Category of information
    fhir:ExplanationOfBenefit.information.code [ Coding ]; # 0..1 Type of information
    # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.information.timingDate [ date ]
      fhir:ExplanationOfBenefit.information.timingPeriod [ Period ]
    # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data. One of these 2
      fhir:ExplanationOfBenefit.information.valueString [ string ]
      fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ]
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    fhir:ExplanationOfBenefit.diagnosis.diagnosis [ Coding ]; # 1..1 Patient's list of diagnosis
    fhir:ExplanationOfBenefit.diagnosis.type [ Coding ], ... ; # 0..* Type of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.drg [ Coding ]; # 0..1 Diagnosis Related Group
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCoding [ Coding ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  # ExplanationOfBenefit.patient[x] : 1..1 The subject of the Products and Services. One of these 2
    fhir:ExplanationOfBenefit.patientIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.patientReference [ Reference(Patient) ]
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.coverage [ # 1..1 Insurance or medical plan
    # ExplanationOfBenefit.coverage.coverage[x] : 0..1 Insurance information. One of these 2
      fhir:ExplanationOfBenefit.coverage.coverageIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.coverage.coverageReference [ Reference(Coverage) ]
    fhir:ExplanationOfBenefit.coverage.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
  ];
  fhir:ExplanationOfBenefit.accident [ # 0..1 
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred
    fhir:ExplanationOfBenefit.accident.type [ Coding ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:ExplanationOfBenefit.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:ExplanationOfBenefit.item.careTeam [ # 0..* 
      # ExplanationOfBenefit.item.careTeam.provider[x] : 1..1 . One of these 2
        fhir:ExplanationOfBenefit.item.careTeam.providerIdentifier [ Identifier ]
        fhir:ExplanationOfBenefit.item.careTeam.providerReference [ Reference(Practitioner|Organization) ]
      fhir:ExplanationOfBenefit.item.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner
      fhir:ExplanationOfBenefit.item.careTeam.role [ Coding ]; # 0..1 Role on the team
      fhir:ExplanationOfBenefit.item.careTeam.qualification [ Coding ]; # 0..1 Type, classification or Specialization
    ], ...;
    fhir:ExplanationOfBenefit.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.revenue [ Coding ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ Coding ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.item.service [ Coding ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.item.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. One of these 3
      fhir:ExplanationOfBenefit.item.locationCoding [ Coding ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.points [ decimal ]; # 0..1 Difficulty scaling factor
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:ExplanationOfBenefit.item.bodySite [ Coding ]; # 0..1 Service Location
    fhir:ExplanationOfBenefit.item.subSite [ Coding ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ Coding ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ExplanationOfBenefit.item.adjudication.reason [ Coding ]; # 0..1 Adjudication reason
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitory value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:ExplanationOfBenefit.item.detail.type [ Coding ]; # 1..1 Group or type of product or service
      fhir:ExplanationOfBenefit.item.detail.revenue [ Coding ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ Coding ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.item.detail.service [ Coding ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.item.detail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
      fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.points [ decimal ]; # 0..1 Difficulty scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:ExplanationOfBenefit.item.detail.subDetail.type [ Coding ]; # 1..1 Type of product or service
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ Coding ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ Coding ]; # 0..1 Type of service or product
        fhir:ExplanationOfBenefit.item.detail.subDetail.service [ Coding ]; # 0..1 Billing Code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ Coding ], ... ; # 0..* Program specific reason for item inclusion
        fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.points [ decimal ]; # 0..1 Difficulty scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* SubDetail adjudication
      ], ...;
    ], ...;
    fhir:ExplanationOfBenefit.item.prosthesis [ # 0..1 Prosthetic details
      fhir:ExplanationOfBenefit.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:ExplanationOfBenefit.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:ExplanationOfBenefit.item.prosthesis.priorMaterial [ Coding ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ExplanationOfBenefit.addItem.revenue [ Coding ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.category [ Coding ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.addItem.service [ Coding ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.addItem.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Added items details
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ Coding ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.category [ Coding ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.addItem.detail.service [ Coding ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ Coding ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.missingTeeth [ # 0..* Only if type = oral
    fhir:ExplanationOfBenefit.missingTeeth.tooth [ Coding ]; # 1..1 Tooth Code
    fhir:ExplanationOfBenefit.missingTeeth.reason [ Coding ]; # 0..1 Reason for missing
    fhir:ExplanationOfBenefit.missingTeeth.extractionDate [ date ]; # 0..1 Date of Extraction
  ], ...;
  fhir:ExplanationOfBenefit.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ExplanationOfBenefit.unallocDeductable [ Money ]; # 0..1 Unallocated deductable
  fhir:ExplanationOfBenefit.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ExplanationOfBenefit.payment [ # 0..1 
    fhir:ExplanationOfBenefit.payment.type [ Coding ]; # 0..1 Partial or Complete
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ Coding ]; # 0..1 Reason for Payment adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ExplanationOfBenefit.form [ Coding ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.note [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ExplanationOfBenefit.note.type [ Coding ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.note.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.note.language [ Coding ]; # 0..1 Language
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ Coding ]; # 1..1 Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ Coding ]; # 0..1 Benefit SubCategory
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:ExplanationOfBenefit.benefitBalance.network [ Coding ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ Coding ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ Coding ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ Coding ]; # 1..1 Deductable, visits, benefit amount
      # ExplanationOfBenefit.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since DSTU2

ExplanationOfBenefit
ExplanationOfBenefit.status added
ExplanationOfBenefit.author[x] added
ExplanationOfBenefit.claim[x] added
ExplanationOfBenefit.claimResponse[x] added
ExplanationOfBenefit.type added
ExplanationOfBenefit.subType added
ExplanationOfBenefit.billablePeriod added
ExplanationOfBenefit.outcome Type changed from code to Coding
Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.provider[x] added
ExplanationOfBenefit.organization[x] Renamed from organization to organization[x]
Add Identifier
ExplanationOfBenefit.facility[x] added
ExplanationOfBenefit.related added
ExplanationOfBenefit.related.claim[x] added
ExplanationOfBenefit.related.relationship added
ExplanationOfBenefit.related.reference added
ExplanationOfBenefit.prescription[x] added
ExplanationOfBenefit.originalPrescription[x] added
ExplanationOfBenefit.payee added
ExplanationOfBenefit.payee.type added
ExplanationOfBenefit.payee.resourceType added
ExplanationOfBenefit.payee.party[x] added
ExplanationOfBenefit.referral[x] added
ExplanationOfBenefit.information added
ExplanationOfBenefit.information.category added
ExplanationOfBenefit.information.code added
ExplanationOfBenefit.information.timing[x] added
ExplanationOfBenefit.information.value[x] added
ExplanationOfBenefit.diagnosis added
ExplanationOfBenefit.diagnosis.sequence added
ExplanationOfBenefit.diagnosis.diagnosis added
ExplanationOfBenefit.diagnosis.type added
ExplanationOfBenefit.diagnosis.drg added
ExplanationOfBenefit.procedure added
ExplanationOfBenefit.procedure.sequence added
ExplanationOfBenefit.procedure.date added
ExplanationOfBenefit.procedure.procedure[x] added
ExplanationOfBenefit.patient[x] added
ExplanationOfBenefit.precedence added
ExplanationOfBenefit.coverage added
ExplanationOfBenefit.coverage.coverage[x] added
ExplanationOfBenefit.coverage.preAuthRef added
ExplanationOfBenefit.accident added
ExplanationOfBenefit.accident.date added
ExplanationOfBenefit.accident.type added
ExplanationOfBenefit.accident.location[x] added
ExplanationOfBenefit.employmentImpacted added
ExplanationOfBenefit.hospitalization added
ExplanationOfBenefit.item added
ExplanationOfBenefit.item.sequence added
ExplanationOfBenefit.item.careTeam added
ExplanationOfBenefit.item.careTeam.provider[x] added
ExplanationOfBenefit.item.careTeam.responsible added
ExplanationOfBenefit.item.careTeam.role added
ExplanationOfBenefit.item.careTeam.qualification added
ExplanationOfBenefit.item.diagnosisLinkId added
ExplanationOfBenefit.item.revenue added
ExplanationOfBenefit.item.category added
ExplanationOfBenefit.item.service added
ExplanationOfBenefit.item.modifier added
ExplanationOfBenefit.item.programCode added
ExplanationOfBenefit.item.serviced[x] added
ExplanationOfBenefit.item.location[x] added
ExplanationOfBenefit.item.quantity added
ExplanationOfBenefit.item.unitPrice added
ExplanationOfBenefit.item.factor added
ExplanationOfBenefit.item.points added
ExplanationOfBenefit.item.net added
ExplanationOfBenefit.item.udi added
ExplanationOfBenefit.item.bodySite added
ExplanationOfBenefit.item.subSite added
ExplanationOfBenefit.item.noteNumber added
ExplanationOfBenefit.item.adjudication added
ExplanationOfBenefit.item.adjudication.category added
ExplanationOfBenefit.item.adjudication.reason added
ExplanationOfBenefit.item.adjudication.amount added
ExplanationOfBenefit.item.adjudication.value added
ExplanationOfBenefit.item.detail added
ExplanationOfBenefit.item.detail.sequence added
ExplanationOfBenefit.item.detail.type added
ExplanationOfBenefit.item.detail.revenue added
ExplanationOfBenefit.item.detail.category added
ExplanationOfBenefit.item.detail.service added
ExplanationOfBenefit.item.detail.modifier added
ExplanationOfBenefit.item.detail.programCode added
ExplanationOfBenefit.item.detail.quantity added
ExplanationOfBenefit.item.detail.unitPrice added
ExplanationOfBenefit.item.detail.factor added
ExplanationOfBenefit.item.detail.points added
ExplanationOfBenefit.item.detail.net added
ExplanationOfBenefit.item.detail.udi added
ExplanationOfBenefit.item.detail.noteNumber added
ExplanationOfBenefit.item.detail.adjudication added
ExplanationOfBenefit.item.detail.subDetail added
ExplanationOfBenefit.item.detail.subDetail.sequence added
ExplanationOfBenefit.item.detail.subDetail.type added
ExplanationOfBenefit.item.detail.subDetail.revenue added
ExplanationOfBenefit.item.detail.subDetail.category added
ExplanationOfBenefit.item.detail.subDetail.service added
ExplanationOfBenefit.item.detail.subDetail.modifier added
ExplanationOfBenefit.item.detail.subDetail.programCode added
ExplanationOfBenefit.item.detail.subDetail.quantity added
ExplanationOfBenefit.item.detail.subDetail.unitPrice added
ExplanationOfBenefit.item.detail.subDetail.factor added
ExplanationOfBenefit.item.detail.subDetail.points added
ExplanationOfBenefit.item.detail.subDetail.net added
ExplanationOfBenefit.item.detail.subDetail.udi added
ExplanationOfBenefit.item.detail.subDetail.noteNumber added
ExplanationOfBenefit.item.detail.subDetail.adjudication added
ExplanationOfBenefit.item.prosthesis added
ExplanationOfBenefit.item.prosthesis.initial added
ExplanationOfBenefit.item.prosthesis.priorDate added
ExplanationOfBenefit.item.prosthesis.priorMaterial added
ExplanationOfBenefit.addItem added
ExplanationOfBenefit.addItem.sequenceLinkId added
ExplanationOfBenefit.addItem.revenue added
ExplanationOfBenefit.addItem.category added
ExplanationOfBenefit.addItem.service added
ExplanationOfBenefit.addItem.modifier added
ExplanationOfBenefit.addItem.fee added
ExplanationOfBenefit.addItem.noteNumber added
ExplanationOfBenefit.addItem.adjudication added
ExplanationOfBenefit.addItem.detail added
ExplanationOfBenefit.addItem.detail.revenue added
ExplanationOfBenefit.addItem.detail.category added
ExplanationOfBenefit.addItem.detail.service added
ExplanationOfBenefit.addItem.detail.modifier added
ExplanationOfBenefit.addItem.detail.fee added
ExplanationOfBenefit.addItem.detail.noteNumber added
ExplanationOfBenefit.addItem.detail.adjudication added
ExplanationOfBenefit.missingTeeth added
ExplanationOfBenefit.missingTeeth.tooth added
ExplanationOfBenefit.missingTeeth.reason added
ExplanationOfBenefit.missingTeeth.extractionDate added
ExplanationOfBenefit.totalCost added
ExplanationOfBenefit.unallocDeductable added
ExplanationOfBenefit.totalBenefit added
ExplanationOfBenefit.payment added
ExplanationOfBenefit.payment.type added
ExplanationOfBenefit.payment.adjustment added
ExplanationOfBenefit.payment.adjustmentReason added
ExplanationOfBenefit.payment.date added
ExplanationOfBenefit.payment.amount added
ExplanationOfBenefit.payment.identifier added
ExplanationOfBenefit.form added
ExplanationOfBenefit.note added
ExplanationOfBenefit.note.number added
ExplanationOfBenefit.note.type added
ExplanationOfBenefit.note.text added
ExplanationOfBenefit.note.language added
ExplanationOfBenefit.benefitBalance added
ExplanationOfBenefit.benefitBalance.category added
ExplanationOfBenefit.benefitBalance.subCategory added
ExplanationOfBenefit.benefitBalance.name added
ExplanationOfBenefit.benefitBalance.description added
ExplanationOfBenefit.benefitBalance.network added
ExplanationOfBenefit.benefitBalance.unit added
ExplanationOfBenefit.benefitBalance.term added
ExplanationOfBenefit.benefitBalance.financial added
ExplanationOfBenefit.benefitBalance.financial.type added
ExplanationOfBenefit.benefitBalance.financial.benefit[x] added
ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] added
ExplanationOfBenefit.request deleted
ExplanationOfBenefit.requestProvider deleted
ExplanationOfBenefit.requestOrganization deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

13.6.2.1 Terminology Bindings

PathDefinitionTypeReference
ExplanationOfBenefit.status A code specifying the state of the resource instance.RequiredExplanationOfBenefitStatus
ExplanationOfBenefit.type The type or discipline-style of the claimRequiredExample Claim Type Codes
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.outcome The result of the claim processingExampleClaim Processing 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.payee.resourceType The type of payee ResourceRequiredPayeeResourceType
ExplanationOfBenefit.information.category The valuset used for additional information category codes.ExampleClaim Information Category Codes
ExplanationOfBenefit.information.code The valuset used for additional information codes.ExampleException Codes
ExplanationOfBenefit.diagnosis.diagnosis ICD10 Diagnostic codesExampleICD-10 Codes
ExplanationOfBenefit.diagnosis.type The type of the diagnosis: admitting, principal, dischargeExampleExample Diagnosis Type Codes
ExplanationOfBenefit.diagnosis.drg The DRG codes associated with the diagnosisExampleExample Diagnosis Related Group Codes
ExplanationOfBenefit.procedure.procedure[x] ICD10 Procedure codesExampleICD-10 Procedure Codes
ExplanationOfBenefit.accident.type Type of accident: work place, auto, etc.RequiredActIncidentCode
ExplanationOfBenefit.item.careTeam.role The role codes for the care team members.ExampleClaim Care Team Role Codes
ExplanationOfBenefit.item.careTeam.qualification Provider professional qualificationsExampleExample Provider Qualification Codes
ExplanationOfBenefit.item.revenue
ExplanationOfBenefit.item.detail.revenue
ExplanationOfBenefit.item.detail.subDetail.revenue
ExplanationOfBenefit.addItem.revenue
ExplanationOfBenefit.addItem.detail.revenue 		Codes for the revenue or cost centers supplying the service and/or products.ExampleExample Revenue Center Codes
ExplanationOfBenefit.item.category
ExplanationOfBenefit.item.detail.category
ExplanationOfBenefit.item.detail.subDetail.category
ExplanationOfBenefit.addItem.category
ExplanationOfBenefit.addItem.detail.category
ExplanationOfBenefit.benefitBalance.subCategory 		Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory 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.modifier
ExplanationOfBenefit.item.detail.modifier
ExplanationOfBenefit.item.detail.subDetail.modifier
ExplanationOfBenefit.addItem.modifier
ExplanationOfBenefit.addItem.detail.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.location[x] 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 The adjudication codes.ExtensibleAdjudication Codes
ExplanationOfBenefit.item.adjudication.reason Adjudication reason codes.ExtensibleAdjudication Reason Codes
ExplanationOfBenefit.item.detail.type
ExplanationOfBenefit.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc.RequiredActInvoiceGroupCode
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.payment.type The type (partial, complete) of the paymentExampleExample Payment Type Codes
ExplanationOfBenefit.payment.adjustmentReason Payment Adjustment reason codes.ExtensiblePayment Adjustment Reason Codes
ExplanationOfBenefit.form The forms codes.RequiredForm Codes
ExplanationOfBenefit.note.type The presentation types of notes.RequiredNoteType
ExplanationOfBenefit.note.language A human language.Extensible, but limited to All LanguagesCommon Languages
ExplanationOfBenefit.benefitBalance.category Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category 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

13.6.3 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
claimidentifiertokenThe 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)