This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Financial Management Work Group | Maturity Level: 2 | Trial Use | Compartments: 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.
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 patient's coverage in respect of that Claim.
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 used and/or remaining.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | DomainResource | Explanation of Benefit resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
identifier | 0..* | Identifier | Business Identifier | |
status | ?!Σ | 0..1 | code | active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus (Required) |
type | 0..1 | CodeableConcept | Type or discipline Example Claim Type Codes (Required) | |
subType | 0..* | CodeableConcept | Finer grained claim type information Example Claim SubType Codes (Example) | |
patient | 0..1 | Reference(Patient) | The subject of the Products and Services | |
billablePeriod | 0..1 | Period | Period for charge submission | |
created | 0..1 | dateTime | Creation date | |
enterer | 0..1 | Reference(Practitioner) | Author | |
insurer | 0..1 | Reference(Organization) | Insurer responsible for the EOB | |
provider | 0..1 | Reference(Practitioner) | Responsible provider for the claim | |
organization | 0..1 | Reference(Organization) | Responsible organization for the claim | |
referral | 0..1 | Reference(ReferralRequest) | Treatment Referral | |
facility | 0..1 | Reference(Location) | Servicing Facility | |
claim | 0..1 | Reference(Claim) | Claim reference | |
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |
outcome | 0..1 | CodeableConcept | complete | error | partial Claim Processing Codes (Example) | |
disposition | 0..1 | string | Disposition Message | |
related | 0..* | BackboneElement | Related Claims which may be revelant to processing this claim | |
claim | 0..1 | Reference(Claim) | Reference to the related claim | |
relationship | 0..1 | CodeableConcept | How the reference claim is related Example Related Claim Relationship Codes (Example) | |
reference | 0..1 | Identifier | Related file or case reference | |
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |
payee | 0..1 | BackboneElement | Party to be paid any benefits payable | |
type | 0..1 | CodeableConcept | Type of party: Subscriber, Provider, other Claim Payee Type Codes (Example) | |
resourceType | 0..1 | CodeableConcept | organization | patient | practitioner | relatedperson PayeeResourceType (Required) | |
party | 0..1 | Reference(Practitioner | Organization | Patient | RelatedPerson) | Party to receive the payable | |
information | 0..* | BackboneElement | Exceptions, special considerations, the condition, situation, prior or concurrent issues | |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | General class of information Claim Information Category Codes (Example) | |
code | 0..1 | CodeableConcept | Type of information Exception Codes (Example) | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Additional Data or supporting information | ||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Any) | |||
reason | 0..1 | Coding | Reason associated with the information Missing Tooth Reason Codes (Example) | |
careTeam | 0..* | BackboneElement | Care Team members | |
sequence | 1..1 | positiveInt | Number to covey order of careteam | |
provider | 1..1 | Reference(Practitioner | Organization) | Member of the Care Team | |
responsible | 0..1 | boolean | Billing practitioner | |
role | 0..1 | CodeableConcept | Role on the team Claim Care Team Role Codes (Example) | |
qualification | 0..1 | CodeableConcept | Type, classification or Specialization Example Provider Qualification Codes (Example) | |
diagnosis | 0..* | BackboneElement | List of Diagnosis | |
sequence | 1..1 | positiveInt | Number to covey order of diagnosis | |
diagnosis[x] | 1..1 | Patient's diagnosis ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Example Diagnosis Type Codes (Example) | |
packageCode | 0..1 | CodeableConcept | Package billing code Example Diagnosis Related Group Codes (Example) | |
procedure | 0..* | BackboneElement | Procedures performed | |
sequence | 1..1 | positiveInt | Procedure sequence for reference | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Patient's list of procedures performed ICD-10 Procedure Codes (Example) | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |
insurance | 0..1 | BackboneElement | Insurance or medical plan | |
coverage | 0..1 | Reference(Coverage) | Insurance information | |
preAuthRef | 0..* | string | Pre-Authorization/Determination Reference | |
accident | 0..1 | BackboneElement | Details of an accident | |
date | 0..1 | date | When the accident occurred | |
type | 0..1 | CodeableConcept | The nature of the accident ActIncidentCode (Required) | |
location[x] | 0..1 | Accident Place | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
employmentImpacted | 0..1 | Period | Period unable to work | |
hospitalization | 0..1 | Period | Period in hospital | |
item | 0..* | BackboneElement | Goods and Services | |
sequence | 1..1 | positiveInt | Service instance | |
careTeamLinkId | 0..* | positiveInt | Applicable careteam members | |
diagnosisLinkId | 0..* | positiveInt | Applicable diagnoses | |
procedureLinkId | 0..* | positiveInt | Applicable procedures | |
informationLinkId | 0..* | positiveInt | Applicable exception and supporting information | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
serviced[x] | 0..1 | Date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
bodySite | 0..1 | CodeableConcept | Service Location Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Service Sub-location Surface Codes (Example) | |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | BackboneElement | Adjudication details | |
category | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
reason | 0..1 | CodeableConcept | Explanation of Adjudication outcome Adjudication Reason Codes (Example) | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitory value | |
detail | 0..* | BackboneElement | Additional items | |
sequence | 1..1 | positiveInt | Service instance | |
type | 1..1 | CodeableConcept | Group or type of product or service ActInvoiceGroupCode (Required) | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total additional item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Additional items | |
sequence | 1..1 | positiveInt | Service instance | |
type | 1..1 | CodeableConcept | Type of product or service ActInvoiceGroupCode (Required) | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Net additional item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Language if different from the resource | |
addItem | 0..* | BackboneElement | Insurer added line items | |
sequenceLinkId | 0..* | positiveInt | Service instances | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
fee | 0..1 | Money | Professional fee or Product charge | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items adjudication | |
detail | 0..* | BackboneElement | Added items details | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
fee | 0..1 | Money | Professional fee or Product charge | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
totalCost | 0..1 | Money | Total Cost of service from the Claim | |
unallocDeductable | 0..1 | Money | Unallocated deductable | |
totalBenefit | 0..1 | Money | Total benefit payable for the Claim | |
payment | 0..1 | BackboneElement | Payment (if paid) | |
type | 0..1 | CodeableConcept | Partial or Complete Example Payment Type Codes (Example) | |
adjustment | 0..1 | Money | Payment adjustment for non-Claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Payment Adjustment Reason Codes (Example) | |
date | 0..1 | date | Expected date of Payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Identifier of the payment instrument | |
form | 0..1 | CodeableConcept | Printed Form Identifier Form Codes (Example) | |
processNote | 0..* | BackboneElement | Processing notes | |
number | 0..1 | positiveInt | Sequence number for this note | |
type | 0..1 | CodeableConcept | display | print | printoper NoteType (Required) | |
text | 0..1 | string | Note explanitory text | |
language | 0..1 | CodeableConcept | Language if different from the resource Common Languages (Extensible but limited to All Languages) | |
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |
category | 1..1 | CodeableConcept | Type of services covered Benefit Category Codes (Example) | |
subCategory | 0..1 | CodeableConcept | Detailed services covered within the type Benefit SubCategory Codes (Example) | |
excluded | 0..1 | boolean | Excluded from the plan | |
name | 0..1 | string | Short name for the benefit | |
description | 0..1 | string | Description of the benefit or services covered | |
network | 0..1 | CodeableConcept | In or out of network Network Type Codes (Example) | |
unit | 0..1 | CodeableConcept | Individual or family Unit Type Codes (Example) | |
term | 0..1 | CodeableConcept | Annual or lifetime Benefit Term Codes (Example) | |
financial | 0..* | BackboneElement | Benefit Summary | |
type | 1..1 | CodeableConcept | Deductable, visits, benefit amount Benefit Type Codes (Example) | |
allowed[x] | 0..1 | Benefits allowed | ||
allowedUnsignedInt | unsignedInt | |||
allowedString | string | |||
allowedMoney | Money | |||
used[x] | 0..1 | Benefits used | ||
usedUnsignedInt | unsignedInt | |||
usedMoney | Money | |||
Documentation for this format |
UML Diagram (Legend)
XML Template
<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier --></identifier> <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error --> <type><!-- 0..1 CodeableConcept Type or discipline --></type> <subType><!-- 0..* CodeableConcept Finer grained claim type information --></subType> <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient> <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod> <created value="[dateTime]"/><!-- 0..1 Creation date --> <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer> <insurer><!-- 0..1 Reference(Organization) Insurer responsible for the EOB --></insurer> <provider><!-- 0..1 Reference(Practitioner) Responsible provider for the claim --></provider> <organization><!-- 0..1 Reference(Organization) Responsible organization for the claim --></organization> <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral> <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility> <claim><!-- 0..1 Reference(Claim) Claim reference --></claim> <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse> <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <related> <!-- 0..* Related Claims which may be revelant to processing this claim --> <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 Related 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 Party to be paid any benefits payable --> <type><!-- 0..1 CodeableConcept Type of party: Subscriber, Provider, other --></type> <resourceType><!-- 0..1 CodeableConcept organization | patient | practitioner | relatedperson --></resourceType> <party><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) Party to receive the payable --></party> </payee> <information> <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <category><!-- 1..1 CodeableConcept General class of 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 string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]> <reason><!-- 0..1 Coding Reason associated with the information --></reason> </information> <careTeam> <!-- 0..* Care Team members --> <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of careteam --> <provider><!-- 1..1 Reference(Practitioner|Organization) Member of the Care Team --></provider> <responsible value="[boolean]"/><!-- 0..1 Billing practitioner --> <role><!-- 0..1 CodeableConcept Role on the team --></role> <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification> </careTeam> <diagnosis> <!-- 0..* List of Diagnosis --> <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis --> <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]> <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type> <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode> </diagnosis> <procedure> <!-- 0..* Procedures performed --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference --> <date value="[dateTime]"/><!-- 0..1 When the procedure was performed --> <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]> </procedure> <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) --> <insurance> <!-- 0..1 Insurance or medical plan --> <coverage><!-- 0..1 Reference(Coverage) Insurance information --></coverage> <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference --> </insurance> <accident> <!-- 0..1 Details of an accident --> <date value="[date]"/><!-- 0..1 When the accident occurred --> <type><!-- 0..1 CodeableConcept The nature of the accident --></type> <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]> </accident> <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted> <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization> <item> <!-- 0..* Goods and Services --> <sequence value="[positiveInt]"/><!-- 1..1 Service instance --> <careTeamLinkId value="[positiveInt]"/><!-- 0..* Applicable careteam members --> <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses --> <procedureLinkId value="[positiveInt]"/><!-- 0..* Applicable procedures --> <informationLinkId value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information --> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Type of service or product --></category> <service><!-- 0..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi> <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite> <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite> <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication> <!-- 0..* Adjudication details --> <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category> <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason> <amount><!-- 0..1 Money Monetary amount --></amount> <value value="[decimal]"/><!-- 0..1 Non-monitory value --> </adjudication> <detail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Service instance --> <type><!-- 1..1 CodeableConcept Group or type of product or service --></type> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Type of service or product --></category> <service><!-- 0..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total additional item cost --></net> <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication> <subDetail> <!-- 0..* Additional items --> <sequence value="[positiveInt]"/><!-- 1..1 Service instance --> <type><!-- 1..1 CodeableConcept Type of product or service --></type> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Type of service or product --></category> <service><!-- 0..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Net additional item cost --></net> <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Language if different from the resource --></adjudication> </subDetail> </detail> </item> <addItem> <!-- 0..* Insurer added line items --> <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances --> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Type of service or product --></category> <service><!-- 0..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <fee><!-- 0..1 Money Professional fee or Product charge --></fee> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication> <detail> <!-- 0..* Added items details --> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Type of service or product --></category> <service><!-- 0..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <fee><!-- 0..1 Money Professional fee or Product charge --></fee> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items detail adjudication --></adjudication> </detail> </addItem> <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost> <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable> <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit> <payment> <!-- 0..1 Payment (if paid) --> <type><!-- 0..1 CodeableConcept Partial or Complete --></type> <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment> <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason> <date value="[date]"/><!-- 0..1 Expected date of Payment --> <amount><!-- 0..1 Money Payable amount after adjustment --></amount> <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier> </payment> <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form> <processNote> <!-- 0..* Processing notes --> <number value="[positiveInt]"/><!-- 0..1 Sequence number for this note --> <type><!-- 0..1 CodeableConcept display | print | printoper --></type> <text value="[string]"/><!-- 0..1 Note explanitory text --> <language><!-- 0..1 CodeableConcept Language if different from the resource --></language> </processNote> <benefitBalance> <!-- 0..* Balance by Benefit Category --> <category><!-- 1..1 CodeableConcept Type of services covered --></category> <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></subCategory> <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 Deductable, visits, benefit amount --></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
{ "resourceType" : "ExplanationOfBenefit", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier "status" : "<code>", // active | cancelled | draft | entered-in-error "type" : { CodeableConcept }, // Type or discipline "subType" : [{ CodeableConcept }], // Finer grained claim type information "patient" : { Reference(Patient) }, // The subject of the Products and Services "billablePeriod" : { Period }, // Period for charge submission "created" : "<dateTime>", // Creation date "enterer" : { Reference(Practitioner) }, // Author "insurer" : { Reference(Organization) }, // Insurer responsible for the EOB "provider" : { Reference(Practitioner) }, // Responsible provider for the claim "organization" : { Reference(Organization) }, // Responsible organization for the claim "referral" : { Reference(ReferralRequest) }, // Treatment Referral "facility" : { Reference(Location) }, // Servicing Facility "claim" : { Reference(Claim) }, // Claim reference "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference "outcome" : { CodeableConcept }, // complete | error | partial "disposition" : "<string>", // Disposition Message "related" : [{ // Related Claims which may be revelant to processing this claim "claim" : { Reference(Claim) }, // Reference to the related claim "relationship" : { CodeableConcept }, // How the reference claim is related "reference" : { Identifier } // Related file or case reference }], "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller "payee" : { // Party to be paid any benefits payable "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable }, "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues "sequence" : "<positiveInt>", // R! Information instance identifier "category" : { CodeableConcept }, // R! General class of information "code" : { CodeableConcept }, // Type of information // timing[x]: When it occurred. One of these 2: "timingDate" : "<date>", "timingPeriod" : { Period }, // value[x]: Additional Data or supporting information. One of these 4: "valueString" : "<string>", "valueQuantity" : { Quantity }, "valueAttachment" : { Attachment }, "valueReference" : { Reference(Any) }, "reason" : { Coding } // Reason associated with the information }], "careTeam" : [{ // Care Team members "sequence" : "<positiveInt>", // R! Number to covey order of careteam "provider" : { Reference(Practitioner|Organization) }, // R! Member of the Care Team "responsible" : <boolean>, // Billing practitioner "role" : { CodeableConcept }, // Role on the team "qualification" : { CodeableConcept } // Type, classification or Specialization }], "diagnosis" : [{ // List of Diagnosis "sequence" : "<positiveInt>", // R! Number to covey order of diagnosis // diagnosis[x]: Patient's diagnosis. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept }, "diagnosisReference" : { Reference(Condition) }, "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis "packageCode" : { CodeableConcept } // Package billing code }], "procedure" : [{ // Procedures performed "sequence" : "<positiveInt>", // R! Procedure sequence for reference "date" : "<dateTime>", // When the procedure was performed // procedure[x]: Patient's list of procedures performed. One of these 2: "procedureCodeableConcept" : { CodeableConcept } "procedureReference" : { Reference(Procedure) } }], "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.) "insurance" : { // Insurance or medical plan "coverage" : { Reference(Coverage) }, // Insurance information "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference }, "accident" : { // Details of an accident "date" : "<date>", // When the accident occurred "type" : { CodeableConcept }, // The nature of the accident // location[x]: Accident Place. One of these 2: "locationAddress" : { Address } "locationReference" : { Reference(Location) } }, "employmentImpacted" : { Period }, // Period unable to work "hospitalization" : { Period }, // Period in hospital "item" : [{ // Goods and Services "sequence" : "<positiveInt>", // R! Service instance "careTeamLinkId" : ["<positiveInt>"], // Applicable careteam members "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses "procedureLinkId" : ["<positiveInt>"], // Applicable procedures "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Type of service or product "service" : { CodeableConcept }, // Billing Code "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion // serviced[x]: Date or dates of Service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique Device Identifier "bodySite" : { CodeableConcept }, // Service Location "subSite" : [{ CodeableConcept }], // Service Sub-location "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ // Adjudication details "category" : { CodeableConcept }, // R! Adjudication category such as co-pay, eligible, benefit, etc. "reason" : { CodeableConcept }, // Explanation of Adjudication outcome "amount" : { Money }, // Monetary amount "value" : <decimal> // Non-monitory value }], "detail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Service instance "type" : { CodeableConcept }, // R! Group or type of product or service "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Type of service or product "service" : { CodeableConcept }, // Billing Code "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total additional item cost "udi" : [{ Reference(Device) }], // Unique Device Identifier "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details "subDetail" : [{ // Additional items "sequence" : "<positiveInt>", // R! Service instance "type" : { CodeableConcept }, // R! Type of product or service "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Type of service or product "service" : { CodeableConcept }, // Billing Code "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Net additional item cost "udi" : [{ Reference(Device) }], // Unique Device Identifier "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Language if different from the resource }] }] }], "addItem" : [{ // Insurer added line items "sequenceLinkId" : ["<positiveInt>"], // Service instances "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Type of service or product "service" : { CodeableConcept }, // Billing Code "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "fee" : { Money }, // Professional fee or Product charge "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication "detail" : [{ // Added items details "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Type of service or product "service" : { CodeableConcept }, // Billing Code "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "fee" : { Money }, // Professional fee or Product charge "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items detail adjudication }] }], "totalCost" : { Money }, // Total Cost of service from the Claim "unallocDeductable" : { Money }, // Unallocated deductable "totalBenefit" : { Money }, // Total benefit payable for the Claim "payment" : { // Payment (if paid) "type" : { CodeableConcept }, // Partial or Complete "adjustment" : { Money }, // Payment adjustment for non-Claim issues "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment "date" : "<date>", // Expected date of Payment "amount" : { Money }, // Payable amount after adjustment "identifier" : { Identifier } // Identifier of the payment instrument }, "form" : { CodeableConcept }, // Printed Form Identifier "processNote" : [{ // Processing notes "number" : "<positiveInt>", // Sequence number for this note "type" : { CodeableConcept }, // display | print | printoper "text" : "<string>", // Note explanitory text "language" : { CodeableConcept } // Language if different from the resource }], "benefitBalance" : [{ // Balance by Benefit Category "category" : { CodeableConcept }, // R! Type of services covered "subCategory" : { CodeableConcept }, // Detailed services covered within the type "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! Deductable, visits, benefit amount // 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/> . [ a fhir:ExplanationOfBenefit; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier fhir:ExplanationOfBenefit.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 0..1 Type or discipline fhir:ExplanationOfBenefit.subType [ CodeableConcept ], ... ; # 0..* Finer grained claim type information fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date fhir:ExplanationOfBenefit.enterer [ Reference(Practitioner) ]; # 0..1 Author fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Insurer responsible for the EOB fhir:ExplanationOfBenefit.provider [ Reference(Practitioner) ]; # 0..1 Responsible provider for the claim fhir:ExplanationOfBenefit.organization [ Reference(Organization) ]; # 0..1 Responsible organization for the claim fhir:ExplanationOfBenefit.referral [ Reference(ReferralRequest) ]; # 0..1 Treatment Referral fhir:ExplanationOfBenefit.facility [ Reference(Location) ]; # 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 [ CodeableConcept ]; # 0..1 complete | error | partial fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claim 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 Related 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 Party to be paid any benefits payable fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other fhir:ExplanationOfBenefit.payee.resourceType [ CodeableConcept ]; # 0..1 organization | patient | practitioner | relatedperson fhir:ExplanationOfBenefit.payee.party [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable ]; fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues fhir:ExplanationOfBenefit.information.sequence [ positiveInt ]; # 1..1 Information instance identifier fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 General class of information fhir:ExplanationOfBenefit.information.code [ CodeableConcept ]; # 0..1 Type of information # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2 fhir:ExplanationOfBenefit.information.timingDate [ date ] fhir:ExplanationOfBenefit.information.timingPeriod [ Period ] # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data or supporting information. One of these 4 fhir:ExplanationOfBenefit.information.valueString [ string ] fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ] fhir:ExplanationOfBenefit.information.valueAttachment [ Attachment ] fhir:ExplanationOfBenefit.information.valueReference [ Reference(Any) ] fhir:ExplanationOfBenefit.information.reason [ Coding ]; # 0..1 Reason associated with the information ], ...; fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Number to covey order of careteam fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Practitioner|Organization) ]; # 1..1 Member of the Care Team fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team fhir:ExplanationOfBenefit.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization ], ...; fhir:ExplanationOfBenefit.diagnosis [ # 0..* List of Diagnosis fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. 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.packageCode [ CodeableConcept ]; # 0..1 Package billing code ], ...; fhir:ExplanationOfBenefit.procedure [ # 0..* Procedures performed fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2 fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ] fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ] ], ...; fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.) fhir:ExplanationOfBenefit.insurance [ # 0..1 Insurance or medical plan fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 0..1 Insurance information fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference ]; fhir:ExplanationOfBenefit.accident [ # 0..1 Details of an accident fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2 fhir:ExplanationOfBenefit.accident.locationAddress [ Address ] fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ] ]; fhir:ExplanationOfBenefit.employmentImpacted [ Period ]; # 0..1 Period unable to work fhir:ExplanationOfBenefit.hospitalization [ Period ]; # 0..1 Period in hospital fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance fhir:ExplanationOfBenefit.item.careTeamLinkId [ positiveInt ], ... ; # 0..* Applicable careteam members fhir:ExplanationOfBenefit.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses fhir:ExplanationOfBenefit.item.procedureLinkId [ positiveInt ], ... ; # 0..* Applicable procedures fhir:ExplanationOfBenefit.item.informationLinkId [ 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 Type of service or product fhir:ExplanationOfBenefit.item.service [ CodeableConcept ]; # 0..1 Billing Code fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2 fhir:ExplanationOfBenefit.item.servicedDate [ date ] fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ] # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. One of these 3 fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ] fhir:ExplanationOfBenefit.item.locationAddress [ Address ] fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ] fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier fhir:ExplanationOfBenefit.item.bodySite [ CodeableConcept ]; # 0..1 Service Location fhir:ExplanationOfBenefit.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location fhir:ExplanationOfBenefit.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc. 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-monitory value ], ...; fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance fhir:ExplanationOfBenefit.item.detail.type [ CodeableConcept ]; # 1..1 Group or type of product or service fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product fhir:ExplanationOfBenefit.item.detail.service [ CodeableConcept ]; # 0..1 Billing Code fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail level adjudication details fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance fhir:ExplanationOfBenefit.item.detail.subDetail.type [ CodeableConcept ]; # 1..1 Type of product or service fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product fhir:ExplanationOfBenefit.item.detail.subDetail.service [ CodeableConcept ]; # 0..1 Billing Code fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Language if different from the resource ], ...; ], ...; ], ...; fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items fhir:ExplanationOfBenefit.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances fhir:ExplanationOfBenefit.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code fhir:ExplanationOfBenefit.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product fhir:ExplanationOfBenefit.addItem.service [ CodeableConcept ]; # 0..1 Billing Code fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ExplanationOfBenefit.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Added items details fhir:ExplanationOfBenefit.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code fhir:ExplanationOfBenefit.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product fhir:ExplanationOfBenefit.addItem.detail.service [ CodeableConcept ]; # 0..1 Billing Code fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ExplanationOfBenefit.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items detail adjudication ], ...; ], ...; fhir:ExplanationOfBenefit.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim fhir:ExplanationOfBenefit.unallocDeductable [ Money ]; # 0..1 Unallocated deductable fhir:ExplanationOfBenefit.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim fhir:ExplanationOfBenefit.payment [ # 0..1 Payment (if paid) fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment 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 Identifier of the payment instrument ]; fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier fhir:ExplanationOfBenefit.processNote [ # 0..* Processing notes fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Sequence number for this note fhir:ExplanationOfBenefit.processNote.type [ CodeableConcept ]; # 0..1 display | print | printoper fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanitory text fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource ], ...; fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered fhir:ExplanationOfBenefit.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type 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 Deductable, visits, benefit amount # 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 DSTU2
ExplanationOfBenefit | |
ExplanationOfBenefit.status |
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ExplanationOfBenefit.type |
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ExplanationOfBenefit.subType |
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ExplanationOfBenefit.patient |
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ExplanationOfBenefit.billablePeriod |
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ExplanationOfBenefit.enterer |
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ExplanationOfBenefit.insurer |
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ExplanationOfBenefit.provider |
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ExplanationOfBenefit.referral |
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ExplanationOfBenefit.facility |
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ExplanationOfBenefit.claim |
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ExplanationOfBenefit.claimResponse |
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ExplanationOfBenefit.outcome |
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ExplanationOfBenefit.related |
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ExplanationOfBenefit.related.claim |
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ExplanationOfBenefit.related.relationship |
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ExplanationOfBenefit.related.reference |
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ExplanationOfBenefit.prescription |
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ExplanationOfBenefit.originalPrescription |
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ExplanationOfBenefit.payee |
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ExplanationOfBenefit.payee.type |
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ExplanationOfBenefit.payee.resourceType |
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ExplanationOfBenefit.payee.party |
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ExplanationOfBenefit.information |
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ExplanationOfBenefit.information.sequence |
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ExplanationOfBenefit.information.category |
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ExplanationOfBenefit.information.code |
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ExplanationOfBenefit.information.timing[x] |
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ExplanationOfBenefit.information.value[x] |
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ExplanationOfBenefit.information.reason |
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ExplanationOfBenefit.careTeam |
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ExplanationOfBenefit.careTeam.sequence |
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ExplanationOfBenefit.careTeam.provider |
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ExplanationOfBenefit.careTeam.responsible |
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ExplanationOfBenefit.careTeam.role |
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ExplanationOfBenefit.careTeam.qualification |
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ExplanationOfBenefit.diagnosis |
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ExplanationOfBenefit.diagnosis.sequence |
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ExplanationOfBenefit.diagnosis.diagnosis[x] |
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ExplanationOfBenefit.diagnosis.type |
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ExplanationOfBenefit.diagnosis.packageCode |
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ExplanationOfBenefit.procedure |
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ExplanationOfBenefit.procedure.sequence |
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ExplanationOfBenefit.procedure.date |
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ExplanationOfBenefit.procedure.procedure[x] |
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ExplanationOfBenefit.precedence |
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ExplanationOfBenefit.insurance |
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ExplanationOfBenefit.insurance.coverage |
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ExplanationOfBenefit.insurance.preAuthRef |
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ExplanationOfBenefit.accident |
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ExplanationOfBenefit.accident.date |
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ExplanationOfBenefit.accident.type |
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ExplanationOfBenefit.accident.location[x] |
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ExplanationOfBenefit.employmentImpacted |
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ExplanationOfBenefit.hospitalization |
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ExplanationOfBenefit.item |
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ExplanationOfBenefit.item.sequence |
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ExplanationOfBenefit.item.careTeamLinkId |
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ExplanationOfBenefit.item.diagnosisLinkId |
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ExplanationOfBenefit.item.procedureLinkId |
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ExplanationOfBenefit.item.informationLinkId |
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ExplanationOfBenefit.item.revenue |
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ExplanationOfBenefit.item.category |
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ExplanationOfBenefit.item.service |
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ExplanationOfBenefit.item.modifier |
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ExplanationOfBenefit.item.programCode |
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ExplanationOfBenefit.item.serviced[x] |
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ExplanationOfBenefit.item.location[x] |
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ExplanationOfBenefit.item.quantity |
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ExplanationOfBenefit.item.unitPrice |
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ExplanationOfBenefit.item.factor |
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ExplanationOfBenefit.item.net |
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ExplanationOfBenefit.item.udi |
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ExplanationOfBenefit.item.bodySite |
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ExplanationOfBenefit.item.subSite |
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ExplanationOfBenefit.item.encounter |
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ExplanationOfBenefit.item.noteNumber |
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ExplanationOfBenefit.item.adjudication |
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ExplanationOfBenefit.item.adjudication.category |
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ExplanationOfBenefit.item.adjudication.reason |
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ExplanationOfBenefit.item.adjudication.amount |
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ExplanationOfBenefit.item.adjudication.value |
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ExplanationOfBenefit.item.detail |
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ExplanationOfBenefit.item.detail.sequence |
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ExplanationOfBenefit.item.detail.type |
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ExplanationOfBenefit.item.detail.revenue |
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ExplanationOfBenefit.item.detail.category |
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ExplanationOfBenefit.item.detail.service |
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ExplanationOfBenefit.item.detail.modifier |
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ExplanationOfBenefit.item.detail.programCode |
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ExplanationOfBenefit.item.detail.quantity |
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ExplanationOfBenefit.item.detail.unitPrice |
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ExplanationOfBenefit.item.detail.factor |
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ExplanationOfBenefit.item.detail.net |
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ExplanationOfBenefit.item.detail.udi |
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ExplanationOfBenefit.item.detail.noteNumber |
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ExplanationOfBenefit.item.detail.adjudication |
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ExplanationOfBenefit.item.detail.subDetail |
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ExplanationOfBenefit.item.detail.subDetail.sequence |
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ExplanationOfBenefit.item.detail.subDetail.type |
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ExplanationOfBenefit.item.detail.subDetail.revenue |
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ExplanationOfBenefit.item.detail.subDetail.category |
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ExplanationOfBenefit.item.detail.subDetail.service |
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ExplanationOfBenefit.item.detail.subDetail.modifier |
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ExplanationOfBenefit.item.detail.subDetail.programCode |
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ExplanationOfBenefit.item.detail.subDetail.quantity |
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ExplanationOfBenefit.item.detail.subDetail.unitPrice |
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ExplanationOfBenefit.item.detail.subDetail.factor |
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ExplanationOfBenefit.item.detail.subDetail.net |
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ExplanationOfBenefit.item.detail.subDetail.udi |
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ExplanationOfBenefit.item.detail.subDetail.noteNumber |
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ExplanationOfBenefit.item.detail.subDetail.adjudication |
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ExplanationOfBenefit.addItem |
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ExplanationOfBenefit.addItem.sequenceLinkId |
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ExplanationOfBenefit.addItem.revenue |
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ExplanationOfBenefit.addItem.category |
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ExplanationOfBenefit.addItem.service |
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ExplanationOfBenefit.addItem.modifier |
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ExplanationOfBenefit.addItem.fee |
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ExplanationOfBenefit.addItem.noteNumber |
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ExplanationOfBenefit.addItem.adjudication |
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ExplanationOfBenefit.addItem.detail |
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ExplanationOfBenefit.addItem.detail.revenue |
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ExplanationOfBenefit.addItem.detail.category |
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ExplanationOfBenefit.addItem.detail.service |
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ExplanationOfBenefit.addItem.detail.modifier |
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ExplanationOfBenefit.addItem.detail.fee |
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ExplanationOfBenefit.addItem.detail.noteNumber |
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ExplanationOfBenefit.addItem.detail.adjudication |
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ExplanationOfBenefit.totalCost |
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ExplanationOfBenefit.unallocDeductable |
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ExplanationOfBenefit.totalBenefit |
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ExplanationOfBenefit.payment |
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ExplanationOfBenefit.payment.type |
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ExplanationOfBenefit.payment.adjustment |
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ExplanationOfBenefit.payment.adjustmentReason |
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ExplanationOfBenefit.payment.date |
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ExplanationOfBenefit.payment.amount |
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ExplanationOfBenefit.payment.identifier |
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ExplanationOfBenefit.form |
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ExplanationOfBenefit.processNote |
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ExplanationOfBenefit.processNote.number |
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ExplanationOfBenefit.processNote.type |
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ExplanationOfBenefit.processNote.text |
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ExplanationOfBenefit.processNote.language |
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ExplanationOfBenefit.benefitBalance |
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ExplanationOfBenefit.benefitBalance.category |
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ExplanationOfBenefit.benefitBalance.subCategory |
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ExplanationOfBenefit.benefitBalance.excluded |
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ExplanationOfBenefit.benefitBalance.name |
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ExplanationOfBenefit.benefitBalance.description |
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ExplanationOfBenefit.benefitBalance.network |
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ExplanationOfBenefit.benefitBalance.unit |
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ExplanationOfBenefit.benefitBalance.term |
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ExplanationOfBenefit.benefitBalance.financial |
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ExplanationOfBenefit.benefitBalance.financial.type |
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ExplanationOfBenefit.benefitBalance.financial.allowed[x] |
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ExplanationOfBenefit.benefitBalance.financial.used[x] |
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ExplanationOfBenefit.request |
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ExplanationOfBenefit.ruleset |
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ExplanationOfBenefit.originalRuleset |
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ExplanationOfBenefit.requestProvider |
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ExplanationOfBenefit.requestOrganization |
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See the Full Difference for further information
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | DomainResource | Explanation of Benefit resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
identifier | 0..* | Identifier | Business Identifier | |
status | ?!Σ | 0..1 | code | active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus (Required) |
type | 0..1 | CodeableConcept | Type or discipline Example Claim Type Codes (Required) | |
subType | 0..* | CodeableConcept | Finer grained claim type information Example Claim SubType Codes (Example) | |
patient | 0..1 | Reference(Patient) | The subject of the Products and Services | |
billablePeriod | 0..1 | Period | Period for charge submission | |
created | 0..1 | dateTime | Creation date | |
enterer | 0..1 | Reference(Practitioner) | Author | |
insurer | 0..1 | Reference(Organization) | Insurer responsible for the EOB | |
provider | 0..1 | Reference(Practitioner) | Responsible provider for the claim | |
organization | 0..1 | Reference(Organization) | Responsible organization for the claim | |
referral | 0..1 | Reference(ReferralRequest) | Treatment Referral | |
facility | 0..1 | Reference(Location) | Servicing Facility | |
claim | 0..1 | Reference(Claim) | Claim reference | |
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |
outcome | 0..1 | CodeableConcept | complete | error | partial Claim Processing Codes (Example) | |
disposition | 0..1 | string | Disposition Message | |
related | 0..* | BackboneElement | Related Claims which may be revelant to processing this claim | |
claim | 0..1 | Reference(Claim) | Reference to the related claim | |
relationship | 0..1 | CodeableConcept | How the reference claim is related Example Related Claim Relationship Codes (Example) | |
reference | 0..1 | Identifier | Related file or case reference | |
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |
payee | 0..1 | BackboneElement | Party to be paid any benefits payable | |
type | 0..1 | CodeableConcept | Type of party: Subscriber, Provider, other Claim Payee Type Codes (Example) | |
resourceType | 0..1 | CodeableConcept | organization | patient | practitioner | relatedperson PayeeResourceType (Required) | |
party | 0..1 | Reference(Practitioner | Organization | Patient | RelatedPerson) | Party to receive the payable | |
information | 0..* | BackboneElement | Exceptions, special considerations, the condition, situation, prior or concurrent issues | |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | General class of information Claim Information Category Codes (Example) | |
code | 0..1 | CodeableConcept | Type of information Exception Codes (Example) | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Additional Data or supporting information | ||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Any) | |||
reason | 0..1 | Coding | Reason associated with the information Missing Tooth Reason Codes (Example) | |
careTeam | 0..* | BackboneElement | Care Team members | |
sequence | 1..1 | positiveInt | Number to covey order of careteam | |
provider | 1..1 | Reference(Practitioner | Organization) | Member of the Care Team | |
responsible | 0..1 | boolean | Billing practitioner | |
role | 0..1 | CodeableConcept | Role on the team Claim Care Team Role Codes (Example) | |
qualification | 0..1 | CodeableConcept | Type, classification or Specialization Example Provider Qualification Codes (Example) | |
diagnosis | 0..* | BackboneElement | List of Diagnosis | |
sequence | 1..1 | positiveInt | Number to covey order of diagnosis | |
diagnosis[x] | 1..1 | Patient's diagnosis ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Example Diagnosis Type Codes (Example) | |
packageCode | 0..1 | CodeableConcept | Package billing code Example Diagnosis Related Group Codes (Example) | |
procedure | 0..* | BackboneElement | Procedures performed | |
sequence | 1..1 | positiveInt | Procedure sequence for reference | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Patient's list of procedures performed ICD-10 Procedure Codes (Example) | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |
insurance | 0..1 | BackboneElement | Insurance or medical plan | |
coverage | 0..1 | Reference(Coverage) | Insurance information | |
preAuthRef | 0..* | string | Pre-Authorization/Determination Reference | |
accident | 0..1 | BackboneElement | Details of an accident | |
date | 0..1 | date | When the accident occurred | |
type | 0..1 | CodeableConcept | The nature of the accident ActIncidentCode (Required) | |
location[x] | 0..1 | Accident Place | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
employmentImpacted | 0..1 | Period | Period unable to work | |
hospitalization | 0..1 | Period | Period in hospital | |
item | 0..* | BackboneElement | Goods and Services | |
sequence | 1..1 | positiveInt | Service instance | |
careTeamLinkId | 0..* | positiveInt | Applicable careteam members | |
diagnosisLinkId | 0..* | positiveInt | Applicable diagnoses | |
procedureLinkId | 0..* | positiveInt | Applicable procedures | |
informationLinkId | 0..* | positiveInt | Applicable exception and supporting information | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
serviced[x] | 0..1 | Date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
bodySite | 0..1 | CodeableConcept | Service Location Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Service Sub-location Surface Codes (Example) | |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | BackboneElement | Adjudication details | |
category | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
reason | 0..1 | CodeableConcept | Explanation of Adjudication outcome Adjudication Reason Codes (Example) | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitory value | |
detail | 0..* | BackboneElement | Additional items | |
sequence | 1..1 | positiveInt | Service instance | |
type | 1..1 | CodeableConcept | Group or type of product or service ActInvoiceGroupCode (Required) | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total additional item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Additional items | |
sequence | 1..1 | positiveInt | Service instance | |
type | 1..1 | CodeableConcept | Type of product or service ActInvoiceGroupCode (Required) | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Net additional item cost | |
udi | 0..* | Reference(Device) | Unique Device Identifier | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Language if different from the resource | |
addItem | 0..* | BackboneElement | Insurer added line items | |
sequenceLinkId | 0..* | positiveInt | Service instances | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
fee | 0..1 | Money | Professional fee or Product charge | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items adjudication | |
detail | 0..* | BackboneElement | Added items details | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Type of service or product Benefit SubCategory Codes (Example) | |
service | 0..1 | CodeableConcept | Billing Code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
fee | 0..1 | Money | Professional fee or Product charge | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
totalCost | 0..1 | Money | Total Cost of service from the Claim | |
unallocDeductable | 0..1 | Money | Unallocated deductable | |
totalBenefit | 0..1 | Money | Total benefit payable for the Claim | |
payment | 0..1 | BackboneElement | Payment (if paid) | |
type | 0..1 | CodeableConcept | Partial or Complete Example Payment Type Codes (Example) | |
adjustment | 0..1 | Money | Payment adjustment for non-Claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Payment Adjustment Reason Codes (Example) | |
date | 0..1 | date | Expected date of Payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Identifier of the payment instrument | |
form | 0..1 | CodeableConcept | Printed Form Identifier Form Codes (Example) | |
processNote | 0..* | BackboneElement | Processing notes | |
number | 0..1 | positiveInt | Sequence number for this note | |
type | 0..1 | CodeableConcept | display | print | printoper NoteType (Required) | |
text | 0..1 | string | Note explanitory text | |
language | 0..1 | CodeableConcept | Language if different from the resource Common Languages (Extensible but limited to All Languages) | |
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |
category | 1..1 | CodeableConcept | Type of services covered Benefit Category Codes (Example) | |
subCategory | 0..1 | CodeableConcept | Detailed services covered within the type Benefit SubCategory Codes (Example) | |
excluded | 0..1 | boolean | Excluded from the plan | |
name | 0..1 | string | Short name for the benefit | |
description | 0..1 | string | Description of the benefit or services covered | |
network | 0..1 | CodeableConcept | In or out of network Network Type Codes (Example) | |
unit | 0..1 | CodeableConcept | Individual or family Unit Type Codes (Example) | |
term | 0..1 | CodeableConcept | Annual or lifetime Benefit Term Codes (Example) | |