Snapshot 3: Connectathon 32 Base

This page is part of the FHIR Specification (v5.0.0-snapshot3: R5 Snapshot #3, to support Connectathon 32). 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

13.10 Resource ExplanationOfBenefit - Content

Financial Management icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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.

13.10.1 Scope and Usage

The ExplanationOfBenefit (EOB) 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 patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.

This is the logical combination of the Claim, ClaimResponse 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 allowed under the policy and the amounts used to date.

Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. It may also be used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. An EOB will never be created for patient or subscriber information exchange if an error was detected in the Claim.

It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. When the resource was originally being developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource for multiple purposes.

Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if the payee is the provider as that would leak business confidential information.

Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. Only the ClaimResponse contains the appropriate adjudication information for a payor response to a Claim.

The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

13.10.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining EOBs: EOBs may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy: 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax: Tax handling of Goods, products, and Services.

13.10.2 Boundaries and Relationships

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.

The eClaim domain includes a number of related resources
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.

13.10.3 References to this Resource

13.10.4 Resource Content

Structure

Name iconFlags iconCard. iconType iconDescription & Constraints icondoco icon
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Author of the claim
... insurer Σ0..1Reference(Organization)Party responsible for reimbursement
... provider Σ0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Process Priority Codes (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Funds Reservation Codes (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
Funds Reservation Codes (Example)
... related 0..*BackboneElementPrior or corollary claims

.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
Claim Payee Type Codes (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... encounter 0..*Reference(Encounter)Encounters related to this billed item

... facility 0..1Reference(Location | Organization)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference

... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... careTeam 0..*BackboneElementCare Team members

.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... specialty 0..1CodeableConceptPractitioner or provider specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information

.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
..... valueIdentifierIdentifier
.... reason 0..1CodingExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information

.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)

.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed

.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)

.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier

... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ0..*BackboneElementPatient insurance information

.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number

... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode icon (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... patientPaid 0..1MoneyPaid by the patient
... item 0..*BackboneElementProduct or service provided

.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members

.... diagnosisSequence 0..*positiveIntApplicable diagnoses

.... procedureSequence 0..*positiveIntApplicable procedures

.... informationSequence 0..*positiveIntApplicable exception and supporting information

.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier

.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Surface Codes (Example)

.... encounter 0..*Reference(Encounter)Encounters related to this billed item

.... noteNumber 0..*positiveIntApplicable note numbers

.... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items

..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier

..... noteNumber 0..*positiveIntApplicable note numbers

..... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdditional items

...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier

...... noteNumber 0..*positiveIntApplicable note numbers

...... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
...... adjudication 0..*see adjudicationSubdetail level adjudication details

... addItem 0..*BackboneElementInsurer added line items

.... itemSequence 0..*positiveIntItem sequence number

.... detailSequence 0..*positiveIntDetail sequence number

.... subDetailSequence 0..*positiveIntSubdetail sequence number

.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers

.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Surface Codes (Example)

.... noteNumber 0..*positiveIntApplicable note numbers

.... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line items

..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
..... adjudication 0..*see adjudicationAdded items adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
...... adjudication 0..*see adjudicationAdded items adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Common Languages (Preferred but limited to AllLanguages)
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category

.... category 1..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary

..... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)A unique identifier assigned to this explanation of benefitidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)ExplanationOfBenefitStatus! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « null (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is soughtpatient : Reference [1..1] « Patient »The period for which charges are being submittedbillablePeriod : Period [0..1]The date this resource was createdcreated : dateTime [1..1]Individual who created the claim, predetermination or preauthorizationenterer : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson »The party responsible for authorization, adjudication and reimbursementinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, normal deferredpriority : CodeableConcept [0..1] « null (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserveRequested : CodeableConcept [0..1] « null (Strength=Example) FundsReservationCodes?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatmentsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « MedicationRequest »The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for servicesreferral : Reference [0..1] « ServiceRequest »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »Facility where the services were providedfacility : Reference [0..1] « Location|Organization »The business identifier for the instance of the adjudication request: claim predetermination or preauthorizationclaim : Reference [0..1] « Claim »The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization responseclaimResponse : Reference [0..1] « ClaimResponse »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « null (Strength=Required)ClaimProcessingCodes! »The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..*]The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as providedpreAuthRefPeriod : Period [0..*]A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »This indicates the relative order of a series of EOBs related to different coverages for the same suite of servicesprecedence : positiveInt [0..1]The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]A code for the form to be used for printing the contentformCode : CodeableConcept [0..1] « null (Strength=Example)FormCodes?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]RelatedClaimReference to a related claimclaim : Reference [0..1] « Claim »A code to convey how the claims are relatedrelationship : CodeableConcept [0..1] « null (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertainsreference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [0..1] « null (Strength=Example)ClaimPayeeTypeCodes?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamA number to uniquely identify care team entriessequence : positiveInt [1..1]Member of the team who provided the product or serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and/or responsible for the claimed products or servicesresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « null (Strength=Example)ClaimCareTeamRoleCodes?? »The specialization of the practitioner or provider which is applicable for this servicespecialty : CodeableConcept [0..1] « null (Strength=Example) ExampleProviderQualificationC...?? »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « null (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is soughtcode : CodeableConcept [0..1] « null (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : DataType [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : DataType [0..1] « boolean|string|Quantity|Attachment| Reference(Any)|Identifier »Provides the reason in the situation where a reason code is required in addition to the contentreason : Coding [0..1] « null (Strength=Example)MissingToothReasonCodes?? »DiagnosisA number to uniquely identify diagnosis entriessequence : positiveInt [1..1]The nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [1..1] « CodeableConcept|Reference(Condition); null (Strength=Example) ICD10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleProcedureTypeCodes?? »Date and optionally time the procedure was performeddate : dateTime [0..1]The code or reference to a Procedure resource which identifies the clinical intervention performedprocedure[x] : DataType [1..1] « CodeableConcept|Reference(Procedure); null (Strength=Example) ICD10ProcedureCodes?? »Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »InsuranceA flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorizationpreAuthRef : string [0..*]AccidentDate of an accident event related to the products and services contained in the claimdate : date [0..1]The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurerstype : CodeableConcept [0..1] « null (Strength=Extensible)ActIncidentCode+ »The physical location of the accident eventlocation[x] : DataType [0..1] « Address|Reference(Location) »ItemA number to uniquely identify item entriessequence : positiveInt [1..1]Care team members related to this service or productcareTeamSequence : positiveInt [0..*]Diagnoses applicable for this service or productdiagnosisSequence : positiveInt [0..*]Procedures applicable for this service or productprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or productinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »ItemBodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AdjudicationA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « null (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »SubDetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details woithin the details within the claim item which this line is intended to replacesubDetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemBodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AddedItemDetailThe type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemDetailSubDetailThe type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »TotalA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [0..1] « null (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « null (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits payable less any payment adjustmentamount : Money [0..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the note texttype : code [0..1] « null (Strength=Required)NoteType! »The explanation or description associated with the processingtext : string [0..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « null (Strength=Preferred)CommonLanguages? »BenefitBalanceCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [1..1] « null (Strength=Example)BenefitCategoryCodes?? »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « null (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « null (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « null (Strength=Example)BenefitTermCodes?? »BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « null (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : DataType [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : DataType [0..1] « unsignedInt|Money »Other claims which are related to this claim such as prior submissions or claims for related services or for the same eventrelated[0..*]The party to be reimbursed for cost of the products and services according to the terms of the policypayee[0..1]The members of the team who provided the products and servicescareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Information about diagnoses relevant to the claim itemsdiagnosis[0..*]Procedures performed on the patient relevant to the billing items with the claimprocedure[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Details of a accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]Physical location where the service is performed or appliesbodySite[0..*]If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this itemadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]Third-tier of goods and servicessubDetail[0..*]Second-tier of goods and servicesdetail[0..*]A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-detailsitem[0..*]Physical location where the service is performed or appliesbodySite[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[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 for the resource --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>
 <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference -->
 <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>
 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)|
    Identifier Data to be provided --></value[x]>
  <reason><!-- 0..1 Coding Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitary value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit classification --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Benefit classification --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[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 for the resource
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Response creation date
  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency
  "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
  "facility" : { Reference(Location|Organization) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : ["<string>"], // Preauthorization reference
  "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "specialty" : { CodeableConcept } // Practitioner or provider specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },
    "reason" : { Coding } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept } // Present on admission
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "preAuthRef" : ["<string>"] // Prior authorization reference number
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident icon
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable care team members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "decision" : { CodeableConcept }, // Result of the adjudication
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitary value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Product or service provided
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "decision" : { CodeableConcept }, // Result of the adjudication
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Product or service provided
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }], // Unique device identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "decision" : { CodeableConcept }, // Result of the adjudication
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "decision" : { CodeableConcept }, // Result of the adjudication
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "decision" : { CodeableConcept }, // Result of the adjudication
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "subDetail" : [{ // Insurer added line items
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "decision" : { CodeableConcept }, // Result of the adjudication
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the variance
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "benefitPeriod" : { Period }, // When the benefits are applicable
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit classification
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Benefit classification
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      "usedUnsignedInt" : "<unsignedInt>",
      "usedMoney" : { 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 for the resource
  fhir:ExplanationOfBenefit.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ExplanationOfBenefit.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 1..1 Response creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Author of the claim
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Party responsible for reimbursement
  fhir:ExplanationOfBenefit.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the claim
  fhir:ExplanationOfBenefit.priority [ CodeableConcept ]; # 0..1 Desired processing urgency
  fhir:ExplanationOfBenefit.fundsReserveRequested [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:ExplanationOfBenefit.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ExplanationOfBenefit.related [ # 0..* Prior or corollary claims
    fhir:ExplanationOfBenefit.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:ExplanationOfBenefit.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 File or case reference
  ], ...;
  fhir:ExplanationOfBenefit.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services or products
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superceded by fulfiller
  fhir:ExplanationOfBenefit.payee [ # 0..1 Recipient of benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Category of recipient
    fhir:ExplanationOfBenefit.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference
  ];
  fhir:ExplanationOfBenefit.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment Referral
  fhir:ExplanationOfBenefit.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
  fhir:ExplanationOfBenefit.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
  fhir:ExplanationOfBenefit.claim [ Reference(Claim) ]; # 0..1 Claim reference
  fhir:ExplanationOfBenefit.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Claim response reference
  fhir:ExplanationOfBenefit.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ExplanationOfBenefit.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.preAuthRef [ string ], ... ; # 0..* Preauthorization reference
  fhir:ExplanationOfBenefit.preAuthRefPeriod [ Period ], ... ; # 0..* Preauthorization in-effect period
  fhir:ExplanationOfBenefit.diagnosisRelatedGroup [ CodeableConcept ]; # 0..1 Package billing code
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:ExplanationOfBenefit.careTeam.specialty [ CodeableConcept ]; # 0..1 Practitioner or provider specialization
  ], ...;
  fhir:ExplanationOfBenefit.supportingInfo [ # 0..* Supporting information
    fhir:ExplanationOfBenefit.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:ExplanationOfBenefit.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.supportingInfo.timingDate [ date ]
      fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [ Period ]
    # ExplanationOfBenefit.supportingInfo.value[x] : 0..1 Data to be provided. One of these 6
      fhir:ExplanationOfBenefit.supportingInfo.valueBoolean [ boolean ]
      fhir:ExplanationOfBenefit.supportingInfo.valueString [ string ]
      fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.supportingInfo.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.supportingInfo.valueReference [ Reference(Any) ]
      fhir:ExplanationOfBenefit.supportingInfo.valueIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.supportingInfo.reason [ Coding ]; # 0..1 Explanation for the information
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:ExplanationOfBenefit.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Clinical procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:ExplanationOfBenefit.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
    fhir:ExplanationOfBenefit.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 0..* Patient insurance information
    fhir:ExplanationOfBenefit.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
  ], ...;
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of the event
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the incident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.patientPaid [ Money ]; # 0..1 Paid by the patient
  fhir:ExplanationOfBenefit.item [ # 0..* Product or service provided
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:ExplanationOfBenefit.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable care team members
    fhir:ExplanationOfBenefit.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:ExplanationOfBenefit.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:ExplanationOfBenefit.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:ExplanationOfBenefit.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.item.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.patientPaid [ Money ]; # 0..1 Paid by the patient
    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 item
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.tax [ Money ]; # 0..1 Total tax
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:ExplanationOfBenefit.item.bodySite [ # 0..* Anatomical location
      fhir:ExplanationOfBenefit.item.bodySite.site [ CodeableReference(BodyStructure) ], ... ; # 1..* Location
      fhir:ExplanationOfBenefit.item.bodySite.subSite [ CodeableConcept ], ... ; # 0..* Sub-location
    ], ...;
    fhir:ExplanationOfBenefit.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.item.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ExplanationOfBenefit.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitary value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Product or service provided
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:ExplanationOfBenefit.item.detail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.item.detail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:ExplanationOfBenefit.item.detail.patientPaid [ Money ]; # 0..1 Paid by the patient
      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 item
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.tax [ Money ]; # 0..1 Total tax
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.item.detail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Product or service provided
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:ExplanationOfBenefit.item.detail.subDetail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:ExplanationOfBenefit.item.detail.subDetail.patientPaid [ Money ]; # 0..1 Paid by the patient
        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 item
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.tax [ Money ]; # 0..1 Total tax
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.item.detail.subDetail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ExplanationOfBenefit.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ExplanationOfBenefit.addItem.subDetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ExplanationOfBenefit.addItem.provider [ Reference(Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Authorized providers
    fhir:ExplanationOfBenefit.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.addItem.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.addItem.servicedDate [ date ]
      fhir:ExplanationOfBenefit.addItem.servicedPeriod [ Period ]
    # ExplanationOfBenefit.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.addItem.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.addItem.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.addItem.patientPaid [ Money ]; # 0..1 Paid by the patient
    fhir:ExplanationOfBenefit.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ExplanationOfBenefit.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ExplanationOfBenefit.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.addItem.tax [ Money ]; # 0..1 Total tax
    fhir:ExplanationOfBenefit.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.addItem.bodySite [ # 0..* Anatomical location
      fhir:ExplanationOfBenefit.addItem.bodySite.site [ CodeableReference(BodyStructure) ], ... ; # 1..* Location
      fhir:ExplanationOfBenefit.addItem.bodySite.subSite [ CodeableConcept ], ... ; # 0..* Sub-location
    ], ...;
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.addItem.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Insurer added line items
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.addItem.detail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.patientPaid [ Money ]; # 0..1 Paid by the patient
      fhir:ExplanationOfBenefit.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ExplanationOfBenefit.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ExplanationOfBenefit.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.addItem.detail.tax [ Money ]; # 0..1 Total tax
      fhir:ExplanationOfBenefit.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.addItem.detail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      fhir:ExplanationOfBenefit.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.patientPaid [ Money ]; # 0..1 Paid by the patient
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.tax [ Money ]; # 0..1 Total tax
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ExplanationOfBenefit.total [ # 0..* Adjudication totals
    fhir:ExplanationOfBenefit.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ExplanationOfBenefit.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment Details
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or complete payment
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the variance
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ExplanationOfBenefit.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ExplanationOfBenefit.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ExplanationOfBenefit.processNote [ # 0..* Note concerning adjudication
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ExplanationOfBenefit.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ExplanationOfBenefit.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit classification
    fhir:ExplanationOfBenefit.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
    fhir:ExplanationOfBenefit.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Benefit classification
      # ExplanationOfBenefit.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since R4

ExplanationOfBenefit
ExplanationOfBenefit.enterer
  • Type Reference: Added Target Types Patient, RelatedPerson
  • Type Reference: Added Target Types Patient, RelatedPerson
ExplanationOfBenefit.insurer
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.provider
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.encounter
  • Added Element
ExplanationOfBenefit.facility
  • Type Reference: Added Target Type Organization
  • Type Reference: Added Target Type Organization
ExplanationOfBenefit.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-snapshot3
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-snapshot3
ExplanationOfBenefit.decision
  • Added Element
ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.supportingInfo.value[x]
  • Add Type Identifier, Identifier
  • Add Type Identifier, Identifier
ExplanationOfBenefit.insurance
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.patientPaid
  • Added Element
ExplanationOfBenefit.item.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.item.bodySite.subSite
  • Added Element
ExplanationOfBenefit.item.decision
  • Added Element
ExplanationOfBenefit.item.detail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.item.detail.decision
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.decision
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.decision
  • Added Element
ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.decision
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.decision
  • Added Element
ExplanationOfBenefit.careTeam.qualification
  • deleted
ExplanationOfBenefit.diagnosis.packageCode
  • deleted
ExplanationOfBenefit.item.subSite
  • deleted
ExplanationOfBenefit.addItem.subSite
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors).)

Structure

Name iconFlags iconCard. iconType iconDescription & Constraints icondoco icon
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Author of the claim
... insurer Σ0..1Reference(Organization)Party responsible for reimbursement
... provider Σ0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Process Priority Codes (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Funds Reservation Codes (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
Funds Reservation Codes (Example)
... related 0..*BackboneElementPrior or corollary claims

.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
Claim Payee Type Codes (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... encounter 0..*Reference(Encounter)Encounters related to this billed item

... facility 0..1Reference(Location | Organization)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference

... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... careTeam 0..*BackboneElementCare Team members

.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... specialty 0..1CodeableConceptPractitioner or provider specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information

.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
..... valueIdentifierIdentifier
.... reason 0..1CodingExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information

.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)

.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed

.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)

.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier

... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ0..*BackboneElementPatient insurance information

.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number

... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode icon (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... patientPaid 0..1MoneyPaid by the patient
... item 0..*BackboneElementProduct or service provided

.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members

.... diagnosisSequence 0..*positiveIntApplicable diagnoses

.... procedureSequence 0..*positiveIntApplicable procedures

.... informationSequence 0..*positiveIntApplicable exception and supporting information

.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier

.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Surface Codes (Example)

.... encounter 0..*Reference(Encounter)Encounters related to this billed item

.... noteNumber 0..*positiveIntApplicable note numbers

.... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items

..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier

..... noteNumber 0..*positiveIntApplicable note numbers

..... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdditional items

...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier

...... noteNumber 0..*positiveIntApplicable note numbers

...... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
...... adjudication 0..*see adjudicationSubdetail level adjudication details

... addItem 0..*BackboneElementInsurer added line items

.... itemSequence 0..*positiveIntItem sequence number

.... detailSequence 0..*positiveIntDetail sequence number

.... subDetailSequence 0..*positiveIntSubdetail sequence number

.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers

.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Surface Codes (Example)

.... noteNumber 0..*positiveIntApplicable note numbers

.... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line items

..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
..... adjudication 0..*see adjudicationAdded items adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... decision 0..1CodeableConceptResult of the adjudication
Claim Adjudication Decision Codes (Example)
...... adjudication 0..*see adjudicationAdded items adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Common Languages (Preferred but limited to AllLanguages)
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category

.... category 1..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary

..... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)A unique identifier assigned to this explanation of benefitidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)ExplanationOfBenefitStatus! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « null (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is soughtpatient : Reference [1..1] « Patient »The period for which charges are being submittedbillablePeriod : Period [0..1]The date this resource was createdcreated : dateTime [1..1]Individual who created the claim, predetermination or preauthorizationenterer : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson »The party responsible for authorization, adjudication and reimbursementinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, normal deferredpriority : CodeableConcept [0..1] « null (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserveRequested : CodeableConcept [0..1] « null (Strength=Example) FundsReservationCodes?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatmentsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « MedicationRequest »The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for servicesreferral : Reference [0..1] « ServiceRequest »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »Facility where the services were providedfacility : Reference [0..1] « Location|Organization »The business identifier for the instance of the adjudication request: claim predetermination or preauthorizationclaim : Reference [0..1] « Claim »The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization responseclaimResponse : Reference [0..1] « ClaimResponse »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « null (Strength=Required)ClaimProcessingCodes! »The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..*]The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as providedpreAuthRefPeriod : Period [0..*]A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »This indicates the relative order of a series of EOBs related to different coverages for the same suite of servicesprecedence : positiveInt [0..1]The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]A code for the form to be used for printing the contentformCode : CodeableConcept [0..1] « null (Strength=Example)FormCodes?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]RelatedClaimReference to a related claimclaim : Reference [0..1] « Claim »A code to convey how the claims are relatedrelationship : CodeableConcept [0..1] « null (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertainsreference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [0..1] « null (Strength=Example)ClaimPayeeTypeCodes?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamA number to uniquely identify care team entriessequence : positiveInt [1..1]Member of the team who provided the product or serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and/or responsible for the claimed products or servicesresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « null (Strength=Example)ClaimCareTeamRoleCodes?? »The specialization of the practitioner or provider which is applicable for this servicespecialty : CodeableConcept [0..1] « null (Strength=Example) ExampleProviderQualificationC...?? »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « null (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is soughtcode : CodeableConcept [0..1] « null (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : DataType [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : DataType [0..1] « boolean|string|Quantity|Attachment| Reference(Any)|Identifier »Provides the reason in the situation where a reason code is required in addition to the contentreason : Coding [0..1] « null (Strength=Example)MissingToothReasonCodes?? »DiagnosisA number to uniquely identify diagnosis entriessequence : positiveInt [1..1]The nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [1..1] « CodeableConcept|Reference(Condition); null (Strength=Example) ICD10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleProcedureTypeCodes?? »Date and optionally time the procedure was performeddate : dateTime [0..1]The code or reference to a Procedure resource which identifies the clinical intervention performedprocedure[x] : DataType [1..1] « CodeableConcept|Reference(Procedure); null (Strength=Example) ICD10ProcedureCodes?? »Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »InsuranceA flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorizationpreAuthRef : string [0..*]AccidentDate of an accident event related to the products and services contained in the claimdate : date [0..1]The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurerstype : CodeableConcept [0..1] « null (Strength=Extensible)ActIncidentCode+ »The physical location of the accident eventlocation[x] : DataType [0..1] « Address|Reference(Location) »ItemA number to uniquely identify item entriessequence : positiveInt [1..1]Care team members related to this service or productcareTeamSequence : positiveInt [0..*]Diagnoses applicable for this service or productdiagnosisSequence : positiveInt [0..*]Procedures applicable for this service or productprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or productinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »ItemBodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AdjudicationA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « null (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »SubDetailA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details woithin the details within the claim item which this line is intended to replacesubDetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemBodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AddedItemDetailThe type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »AddedItemDetailSubDetailThe type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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]The total of taxes applicable for this product or servicetax : Money [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »TotalA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [0..1] « null (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « null (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits payable less any payment adjustmentamount : Money [0..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the note texttype : code [0..1] « null (Strength=Required)NoteType! »The explanation or description associated with the processingtext : string [0..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « null (Strength=Preferred)CommonLanguages? »BenefitBalanceCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [1..1] « null (Strength=Example)BenefitCategoryCodes?? »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « null (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « null (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « null (Strength=Example)BenefitTermCodes?? »BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « null (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : DataType [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : DataType [0..1] « unsignedInt|Money »Other claims which are related to this claim such as prior submissions or claims for related services or for the same eventrelated[0..*]The party to be reimbursed for cost of the products and services according to the terms of the policypayee[0..1]The members of the team who provided the products and servicescareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Information about diagnoses relevant to the claim itemsdiagnosis[0..*]Procedures performed on the patient relevant to the billing items with the claimprocedure[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Details of a accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]Physical location where the service is performed or appliesbodySite[0..*]If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this itemadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]Third-tier of goods and servicessubDetail[0..*]Second-tier of goods and servicesdetail[0..*]A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-detailsitem[0..*]Physical location where the service is performed or appliesbodySite[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The adjudication resultsadjudication[0..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[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 for the resource --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>
 <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference -->
 <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>
 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)|
    Identifier Data to be provided --></value[x]>
  <reason><!-- 0..1 Coding Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitary value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit classification --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Benefit classification --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[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 for the resource
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Response creation date
  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency
  "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
  "facility" : { Reference(Location|Organization) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : ["<string>"], // Preauthorization reference
  "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "specialty" : { CodeableConcept } // Practitioner or provider specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },
    "reason" : { Coding } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept } // Present on admission
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "preAuthRef" : ["<string>"] // Prior authorization reference number
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident icon
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable care team members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "decision" : { CodeableConcept }, // Result of the adjudication
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitary value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Product or service provided
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "decision" : { CodeableConcept }, // Result of the adjudication
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Product or service provided
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }], // Unique device identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "decision" : { CodeableConcept }, // Result of the adjudication
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "decision" : { CodeableConcept }, // Result of the adjudication
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "decision" : { CodeableConcept }, // Result of the adjudication
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "subDetail" : [{ // Insurer added line items
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "decision" : { CodeableConcept }, // Result of the adjudication
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the variance
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "benefitPeriod" : { Period }, // When the benefits are applicable
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit classification
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Benefit classification
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      "usedUnsignedInt" : "<unsignedInt>",
      "usedMoney" : { 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 for the resource
  fhir:ExplanationOfBenefit.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ExplanationOfBenefit.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 1..1 Response creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Author of the claim
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Party responsible for reimbursement
  fhir:ExplanationOfBenefit.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the claim
  fhir:ExplanationOfBenefit.priority [ CodeableConcept ]; # 0..1 Desired processing urgency
  fhir:ExplanationOfBenefit.fundsReserveRequested [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:ExplanationOfBenefit.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ExplanationOfBenefit.related [ # 0..* Prior or corollary claims
    fhir:ExplanationOfBenefit.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:ExplanationOfBenefit.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 File or case reference
  ], ...;
  fhir:ExplanationOfBenefit.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services or products
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superceded by fulfiller
  fhir:ExplanationOfBenefit.payee [ # 0..1 Recipient of benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Category of recipient
    fhir:ExplanationOfBenefit.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference
  ];
  fhir:ExplanationOfBenefit.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment Referral
  fhir:ExplanationOfBenefit.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
  fhir:ExplanationOfBenefit.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
  fhir:ExplanationOfBenefit.claim [ Reference(Claim) ]; # 0..1 Claim reference
  fhir:ExplanationOfBenefit.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Claim response reference
  fhir:ExplanationOfBenefit.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ExplanationOfBenefit.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.preAuthRef [ string ], ... ; # 0..* Preauthorization reference
  fhir:ExplanationOfBenefit.preAuthRefPeriod [ Period ], ... ; # 0..* Preauthorization in-effect period
  fhir:ExplanationOfBenefit.diagnosisRelatedGroup [ CodeableConcept ]; # 0..1 Package billing code
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:ExplanationOfBenefit.careTeam.specialty [ CodeableConcept ]; # 0..1 Practitioner or provider specialization
  ], ...;
  fhir:ExplanationOfBenefit.supportingInfo [ # 0..* Supporting information
    fhir:ExplanationOfBenefit.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:ExplanationOfBenefit.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.supportingInfo.timingDate [ date ]
      fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [ Period ]
    # ExplanationOfBenefit.supportingInfo.value[x] : 0..1 Data to be provided. One of these 6
      fhir:ExplanationOfBenefit.supportingInfo.valueBoolean [ boolean ]
      fhir:ExplanationOfBenefit.supportingInfo.valueString [ string ]
      fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.supportingInfo.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.supportingInfo.valueReference [ Reference(Any) ]
      fhir:ExplanationOfBenefit.supportingInfo.valueIdentifier [ Identifier ]
    fhir:ExplanationOfBenefit.supportingInfo.reason [ Coding ]; # 0..1 Explanation for the information
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:ExplanationOfBenefit.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Clinical procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:ExplanationOfBenefit.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
    fhir:ExplanationOfBenefit.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 0..* Patient insurance information
    fhir:ExplanationOfBenefit.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
  ], ...;
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of the event
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the incident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.patientPaid [ Money ]; # 0..1 Paid by the patient
  fhir:ExplanationOfBenefit.item [ # 0..* Product or service provided
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:ExplanationOfBenefit.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable care team members
    fhir:ExplanationOfBenefit.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:ExplanationOfBenefit.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:ExplanationOfBenefit.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:ExplanationOfBenefit.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.item.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.patientPaid [ Money ]; # 0..1 Paid by the patient
    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 item
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.tax [ Money ]; # 0..1 Total tax
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:ExplanationOfBenefit.item.bodySite [ # 0..* Anatomical location
      fhir:ExplanationOfBenefit.item.bodySite.site [ CodeableReference(BodyStructure) ], ... ; # 1..* Location
      fhir:ExplanationOfBenefit.item.bodySite.subSite [ CodeableConcept ], ... ; # 0..* Sub-location
    ], ...;
    fhir:ExplanationOfBenefit.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.item.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ExplanationOfBenefit.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitary value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Product or service provided
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:ExplanationOfBenefit.item.detail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.item.detail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:ExplanationOfBenefit.item.detail.patientPaid [ Money ]; # 0..1 Paid by the patient
      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 item
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.tax [ Money ]; # 0..1 Total tax
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.item.detail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Product or service provided
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:ExplanationOfBenefit.item.detail.subDetail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:ExplanationOfBenefit.item.detail.subDetail.patientPaid [ Money ]; # 0..1 Paid by the patient
        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 item
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.tax [ Money ]; # 0..1 Total tax
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.item.detail.subDetail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ExplanationOfBenefit.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ExplanationOfBenefit.addItem.subDetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ExplanationOfBenefit.addItem.provider [ Reference(Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Authorized providers
    fhir:ExplanationOfBenefit.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:ExplanationOfBenefit.addItem.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ExplanationOfBenefit.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ExplanationOfBenefit.addItem.servicedDate [ date ]
      fhir:ExplanationOfBenefit.addItem.servicedPeriod [ Period ]
    # ExplanationOfBenefit.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ExplanationOfBenefit.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.addItem.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.addItem.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.addItem.patientPaid [ Money ]; # 0..1 Paid by the patient
    fhir:ExplanationOfBenefit.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ExplanationOfBenefit.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ExplanationOfBenefit.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.addItem.tax [ Money ]; # 0..1 Total tax
    fhir:ExplanationOfBenefit.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.addItem.bodySite [ # 0..* Anatomical location
      fhir:ExplanationOfBenefit.addItem.bodySite.site [ CodeableReference(BodyStructure) ], ... ; # 1..* Location
      fhir:ExplanationOfBenefit.addItem.bodySite.subSite [ CodeableConcept ], ... ; # 0..* Sub-location
    ], ...;
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ExplanationOfBenefit.addItem.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Insurer added line items
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:ExplanationOfBenefit.addItem.detail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.patientPaid [ Money ]; # 0..1 Paid by the patient
      fhir:ExplanationOfBenefit.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ExplanationOfBenefit.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ExplanationOfBenefit.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.addItem.detail.tax [ Money ]; # 0..1 Total tax
      fhir:ExplanationOfBenefit.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ExplanationOfBenefit.addItem.detail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      fhir:ExplanationOfBenefit.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd [ CodeableConcept ]; # 0..1 End of a range of codes
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.patientPaid [ Money ]; # 0..1 Paid by the patient
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.tax [ Money ]; # 0..1 Total tax
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.decision [ CodeableConcept ]; # 0..1 Result of the adjudication
        fhir:ExplanationOfBenefit.addItem.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ExplanationOfBenefit.total [ # 0..* Adjudication totals
    fhir:ExplanationOfBenefit.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ExplanationOfBenefit.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment Details
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or complete payment
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the variance
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ExplanationOfBenefit.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ExplanationOfBenefit.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ExplanationOfBenefit.processNote [ # 0..* Note concerning adjudication
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ExplanationOfBenefit.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ExplanationOfBenefit.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit classification
    fhir:ExplanationOfBenefit.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
    fhir:ExplanationOfBenefit.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Benefit classification
      # ExplanationOfBenefit.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since Release 4

ExplanationOfBenefit
ExplanationOfBenefit.enterer
  • Type Reference: Added Target Types Patient, RelatedPerson
  • Type Reference: Added Target Types Patient, RelatedPerson
ExplanationOfBenefit.insurer
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.provider
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.encounter
  • Added Element
ExplanationOfBenefit.facility
  • Type Reference: Added Target Type Organization
  • Type Reference: Added Target Type Organization
ExplanationOfBenefit.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-snapshot3
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-snapshot3
ExplanationOfBenefit.decision
  • Added Element
ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.supportingInfo.value[x]
  • Add Type Identifier, Identifier
  • Add Type Identifier, Identifier
ExplanationOfBenefit.insurance
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.patientPaid
  • Added Element
ExplanationOfBenefit.item.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.item.bodySite.subSite
  • Added Element
ExplanationOfBenefit.item.decision
  • Added Element
ExplanationOfBenefit.item.detail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.item.detail.decision
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.decision
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.decision
  • Added Element
ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.decision
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
  • Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.decision
  • Added Element
ExplanationOfBenefit.careTeam.qualification
  • deleted
ExplanationOfBenefit.diagnosis.packageCode
  • deleted
ExplanationOfBenefit.item.subSite
  • deleted
ExplanationOfBenefit.addItem.subSite
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors).)

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.10.4.1 Terminology Bindings

PathDefinitionTypeReference
ExplanationOfBenefit.status

A code specifying the state of the resource instance.

RequiredExplanationOfBenefitStatus
ExplanationOfBenefit.type

This value set includes Claim Type codes.

ExtensibleClaimTypeCodes
ExplanationOfBenefit.subType

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.

ExampleExampleClaimSubTypeCodes
ExplanationOfBenefit.use

The purpose of the Claim: predetermination, preauthorization, claim.

RequiredUse
ExplanationOfBenefit.priority

This value set includes the financial processing priority codes.

ExampleProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequested

This value set includes sample funds reservation type codes.

ExampleFundsReservationCodes
ExplanationOfBenefit.fundsReserve

This value set includes sample funds reservation type codes.

ExampleFundsReservationCodes
ExplanationOfBenefit.related.relationship

This value set includes sample Related Claim Relationship codes.

ExampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.type

This value set includes sample Payee Type codes.

ExampleClaimPayeeTypeCodes
ExplanationOfBenefit.outcome

This value set includes Claim Processing Outcome codes.

RequiredClaimProcessingCodes (a valid code from Claim Processing Outcome Codes)
ExplanationOfBenefit.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.diagnosisRelatedGroup

This value set includes example Diagnosis Related Group codes.

ExampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.careTeam.role

This value set includes sample Claim Care Team Role codes.

ExampleClaimCareTeamRoleCodes
ExplanationOfBenefit.careTeam.specialty

This value set includes sample Provider Qualification codes.

ExampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.category

This value set includes sample Information Category codes.

ExampleClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo.code

This value set includes sample Exception codes.

ExampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reason

This value set includes sample Missing Tooth Reason codes.

ExampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]

This value set includes sample ICD-10 codes.

ExampleICD10Codes (a valid code from ICD-10 icon)
ExplanationOfBenefit.diagnosis.type

This value set includes example Diagnosis Type codes.

ExampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmission

This value set includes example Diagnosis on Admission codes.

ExampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.procedure.type

This value set includes example Procedure Type codes.

ExampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]

This value set includes sample ICD-10 Procedure codes.

ExampleICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes)
ExplanationOfBenefit.accident.type

Set of codes indicating the type of incident or accident.

ExtensibleActIncidentCode icon
ExplanationOfBenefit.item.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.category

This value set includes examples of Benefit Category codes.

ExampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.item.programCode

This value set includes sample Program Reason Span codes.

ExampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]

This value set includes a smattering of Service Place codes.

ExampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySite.site

This value set includes a smattering of FDI oral site codes.

ExampleOralSiteCodes
ExplanationOfBenefit.item.bodySite.subSite

This value set includes a smattering of FDI tooth surface codes.

ExampleSurfaceCodes
ExplanationOfBenefit.item.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.item.adjudication.category

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

ExampleAdjudicationValueCodes
ExplanationOfBenefit.item.adjudication.reason

This value set includes smattering of Adjudication Reason codes.

ExampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.category

This value set includes examples of Benefit Category codes.

ExampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.detail.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCode

This value set includes sample Program Reason Span codes.

ExampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.item.detail.subDetail.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.category

This value set includes examples of Benefit Category codes.

ExampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCode

This value set includes sample Program Reason Span codes.

ExampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.addItem.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.addItem.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCode

This value set includes sample Program Reason Span codes.

ExampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]

This value set includes a smattering of Service Place codes.

ExampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySite.site

This value set includes a smattering of FDI oral site codes.

ExampleOralSiteCodes
ExplanationOfBenefit.addItem.bodySite.subSite

This value set includes a smattering of FDI tooth surface codes.

ExampleSurfaceCodes
ExplanationOfBenefit.addItem.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.addItem.detail.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.addItem.detail.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.addItem.detail.subDetail.revenue

This value set includes sample Revenue Center codes.

ExampleExampleRevenueCenterCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.decision

This value set includes Claim Adjudication Decision codes.

ExampleClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)
ExplanationOfBenefit.total.category

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

ExampleAdjudicationValueCodes
ExplanationOfBenefit.payment.type

This value set includes example Payment Type codes.

ExampleExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReason

This value set includes smattering of Payment Adjustment Reason codes.

ExamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCode

This value set includes a sample set of Forms codes.

ExampleFormCodes
ExplanationOfBenefit.processNote.type

The presentation types of notes.

RequiredNoteType
ExplanationOfBenefit.processNote.language

This value set includes common codes from BCP-47 (http://tools.ietf.org/html/bcp47)

Preferred, but limited to AllLanguagesCommonLanguages
ExplanationOfBenefit.benefitBalance.category

This value set includes examples of Benefit Category codes.

ExampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.network

This value set includes a smattering of Network type codes.

ExampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unit

This value set includes a smattering of Unit type codes.

ExampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.term

This value set includes a smattering of Benefit Term codes.

ExampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.type

This value set includes a smattering of Benefit type codes.

ExampleBenefitTypeCodes

13.10.5 Search Parameters

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

NameTypeDescriptionExpressionIn Common
care-teamreferenceMember of the CareTeamExplanationOfBenefit.careTeam.provider
(Practitioner, Organization, PractitionerRole)
claimreferenceThe reference to the claimExplanationOfBenefit.claim
(Claim)
coveragereferenceThe plan under which the claim was adjudicatedExplanationOfBenefit.insurance.coverage
(Coverage)
createddateThe creation date for the EOBExplanationOfBenefit.created
detail-udireferenceUDI associated with a line item detail product or serviceExplanationOfBenefit.item.detail.udi
(Device)
dispositionstringThe contents of the disposition messageExplanationOfBenefit.disposition
encounterreferenceEncounters associated with a billed line itemExplanationOfBenefit.item.encounter
(Encounter)
entererreferenceThe party responsible for the entry of the ClaimExplanationOfBenefit.enterer
(Practitioner, Patient, PractitionerRole, RelatedPerson)
facilityreferenceFacility responsible for the goods and servicesExplanationOfBenefit.facility
(Organization, Location)
identifiertokenThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier
item-udireferenceUDI associated with a line item product or serviceExplanationOfBenefit.item.udi
(Device)
patientreferenceThe reference to the patientExplanationOfBenefit.patient
(Patient)
payeereferenceThe party receiving any payment for the ClaimExplanationOfBenefit.payee.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
procedure-udireferenceUDI associated with a procedureExplanationOfBenefit.procedure.udi
(Device)
providerreferenceThe reference to the providerExplanationOfBenefit.provider
(Practitioner, Organization, PractitionerRole)
statustokenStatus of the instanceExplanationOfBenefit.status
subdetail-udireferenceUDI associated with a line item detail subdetail product or serviceExplanationOfBenefit.item.detail.subDetail.udi
(Device)