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7.6 Resource ExplanationOfBenefit - Content

This resource maintained by the Financial Management Work Group

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

7.6.1 Scope and Usage

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

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

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

Todo

7.6.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceRemittance resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1ClaimClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization

XML Template

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

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(Claim) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceRemittance resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1ClaimClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization

XML Template

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

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(Claim) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

 

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

7.6.2.1 Terminology Bindings

PathDefinitionTypeReference
ExplanationOfBenefit.outcome The outcome of the processing.Requiredhttp://hl7.org/fhir/RS-link
ExplanationOfBenefit.ruleset
ExplanationOfBenefit.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset

7.6.3 Search Parameters

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

NameTypeDescriptionPaths
identifiertokenThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier