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.

A unique identifier assigned to this explanation of benefit.

Allows EOBs to be distinguished and referenced.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes such as the US UB-04 bill type code.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

This element is required to understand the nature of the request for adjudication.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

The period for which charges are being submitted.

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Individual who created the claim, predetermination or preauthorization.

Some jurisdictions require the contact information for personnel completing claims.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

The provider which is responsible for the claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

A code to indicate whether and for whom funds are to be reserved for future claims.

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

This field is only used for preauthorizations.

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

For workplace or other accidents it is common to relate separate claims arising from the same event.

For example, for the original treatment and follow-up exams.

Reference to a related claim.

For workplace or other accidents it is common to relate separate claims arising from the same event.

A code to convey how the claims are related.

Some insurers need a declaration of the type of relationship.

For example, prior claim or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains.

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

For example, Property/Casualty insurer claim number or Workers Compensation case number.

Prescription to support the dispensing of pharmacy, device or vision products.

Required to authorize the dispensing of controlled substances and devices.

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

The party to be reimbursed for cost of the products and services according to the terms of the policy.

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

Type of Party to be reimbursed: Subscriber, provider, other.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Reference to the individual or organization to whom any payment will be made.

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Not required if the payee is 'subscriber' or 'provider'.

A reference to a referral resource.

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

The referral resource which lists the date, practitioner, reason and other supporting information.

Facility where the services were provided.

Insurance adjudication can be dependant on where services were delivered.

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

To provide a link to the original adjudication request.

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

To provide a link to the original adjudication response.

The outcome of the claim, predetermination, or preauthorization processing.

To advise the requestor of an overall processing outcome.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

A human readable description of the status of the adjudication.

Provided for user display.

Reference from the Insurer which is used in later communications which refers to this adjudication.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The members of the team who provided the products and services.

Common to identify the responsible and supporting practitioners.

A number to uniquely identify care team entries.

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Member of the team who provided the product or service.

Often a regulatory requirement to specify the responsible provider.

The party who is billing and/or responsible for the claimed products or services.

When multiple parties are present it is required to distinguish the lead or responsible individual.

Responsible might not be required when there is only a single provider listed.

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

When multiple parties are present it is required to distinguish the roles performed by each member.

Role might not be required when there is only a single provider listed.

The qualification of the practitioner which is applicable for this service.

Need to specify which qualification a provider is delivering the product or service under.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Often there are multiple jurisdiction specific valuesets which are required.

A number to uniquely identify supporting information entries.

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

This may contain a category for the local bill type codes.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Required to identify the kind of additional information.

This may contain the local bill type codes such as the US UB-04 bill type code.

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

To convey the data content to be provided when the information is more than a simple code or period.

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

Provides the reason in the situation where a reason code is required in addition to the content.

Needed when the supporting information has both a date and amount/value and requires explanation.

For example: the reason for the additional stay, or why a tooth is missing.

Information about diagnoses relevant to the claim items.

Required for the adjudication by provided context for the services and product listed.

A number to uniquely identify diagnosis entries.

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Provides health context for the evaluation of the products and/or services.

When the condition was observed or the relative ranking.

Often required to capture a particular diagnosis, for example: primary or discharge.

For example: admitting, primary, secondary, discharge.

Indication of whether the diagnosis was present on admission to a facility.

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

Procedures performed on the patient relevant to the billing items with the claim.

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

A number to uniquely identify procedure entries.

Necessary to provide a mechanism to link to claim details.

When the condition was observed or the relative ranking.

Often required to capture a particular diagnosis, for example: primary or discharge.

Date and optionally time the procedure was performed.

Required for auditing purposes.

The code or reference to a Procedure resource which identifies the clinical intervention performed.

This identifies the actual clinical procedure.

Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to obtain device level information on the product supplied.

This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.

Needed to coordinate between multiple EOBs for the same suite of services.

Financial instruments for reimbursement for the health care products and services specified on the claim.

At least one insurer is required for a claim to be a claim.

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

To identify which coverage in the list is being used to adjudicate this claim.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Required to allow the adjudicator to locate the correct policy and history within their information system.

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

Details of a accident which resulted in injuries which required the products and services listed in the claim.

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

Date of an accident event related to the products and services contained in the claim.

Required for audit purposes and adjudication.

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Coverage may be dependant on the type of accident.

The physical location of the accident event.

Required for audit purposes and determination of applicable insurance liability.

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

The items to be processed for adjudication.

A number to uniquely identify item entries.

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Care team members related to this service or product.

Need to identify the individuals and their roles in the provision of the product or service.

Diagnoses applicable for this service or product.

Need to related the product or service to the associated diagnoses.

Procedures applicable for this service or product.

Need to provide any listed specific procedures to support the product or service being claimed.

Exceptions, special conditions and supporting information applicable for this service or product.

Need to reference the supporting information items that relate directly to this product or service.

The type of revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Code to identify the general type of benefits under which products and services are provided.

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Identifies the program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The date or dates when the service or product was supplied, performed or completed.

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Where the product or service was provided.

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to obtain device level information on the product supplied.

Physical service site on the patient (limb, tooth, etc.).

Allows insurer to validate specific procedures.

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Allows insurer to validate specific procedures.

A billed item may include goods or services provided in multiple encounters.

Used in some jurisdictions to link clinical events to claim items.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Needed to enable understanding of the context of the other information in the adjudication.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

To support understanding of variance from adjudication expectations.

For example, may indicate that the funds for this benefit type have been exhausted.

Monetary amount associated with the category.

Most adjuciation categories convey a monetary amount.

For example, amount submitted, eligible amount, co-payment, and benefit payable.

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Some adjudication categories convey a percentage or a fixed value.

For example: eligible percentage or co-payment percentage.

Second-tier of goods and services.

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

The items to be processed for adjudication.

The type of revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Code to identify the general type of benefits under which products and services are provided.

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Identifies the program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to obtain device level information on the product supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

Third-tier of goods and services.

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

The items to be processed for adjudication.

The type of revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Code to identify the general type of benefits under which products and services are provided.

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Identifies the program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to obtain device level information on the product supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The first-tier service adjudications for payor added product or service lines.

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Claim items which this service line is intended to replace.

Provides references to the claim items.

The sequence number of the details within the claim item which this line is intended to replace.

Provides references to the claim details within the claim item.

The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

Provides references to the claim sub-details within the claim detail.

The providers who are authorized for the services rendered to the patient.

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Identifies the program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The date or dates when the service or product was supplied, performed or completed.

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Where the product or service was provided.

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Physical service site on the patient (limb, tooth, etc.).

Allows insurer to validate specific procedures.

For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Allows insurer to validate specific procedures.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The second-tier service adjudications for payor added services.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The third-tier service adjudications for payor added services.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Categorized monetary totals for the adjudication.

To provide the requestor with financial totals by category for the adjudication.

Totals for amounts submitted, co-pays, benefits payable etc.

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Needed to convey the type of total provided.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Monetary total amount associated with the category.

Needed to convey the total monetary amount.

Payment details for the adjudication of the claim.

Needed to convey references to the financial instrument that has been used if payment has been made.

Whether this represents partial or complete payment of the benefits payable.

To advise the requestor when the insurer believes all payments to have been completed.

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

To advise the requestor of adjustments applied to the payment.

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

Reason for the payment adjustment.

Needed to clarify the monetary adjustment.

Estimated date the payment will be issued or the actual issue date of payment.

To advise the payee when payment can be expected.

Benefits payable less any payment adjustment.

Needed to provide the actual payment amount.

Issuer's unique identifier for the payment instrument.

Enable the receiver to reconcile when payment received.

For example: EFT number or check number.

A code for the form to be used for printing the content.

Needed to specify the specific form used for producing output for this response.

May be needed to identify specific jurisdictional forms.

The actual form, by reference or inclusion, for printing the content or an EOB.

Needed to include the specific form used for producing output for this response.

Needed to permit insurers to include the actual form.

A note that describes or explains adjudication results in a human readable form.

Provides the insurer specific textual explanations associated with the processing.

A number to uniquely identify a note entry.

Necessary to provide a mechanism to link from adjudications.

The business purpose of the note text.

To convey the expectation for when the text is used.

The explanation or description associated with the processing.

Required to provide human readable explanation.

A code to define the language used in the text of the note.

Note text may vary from the resource defined language.

Only required if the language is different from the resource language.

The term of the benefits documented in this response.

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Not applicable when use=claim.

Balance by Benefit Category.

Code to identify the general type of benefits under which products and services are provided.

Needed to convey the category of service or product for which eligibility is sought.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Needed to identify items that are specifically excluded from the coverage.

A short name or tag for the benefit.

Required to align with other plan names.

For example: MED01, or DENT2.

A richer description of the benefit or services covered.

Needed for human readable reference.

For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Needed as in or out of network providers are treated differently under the coverage.

Indicates if the benefits apply to an individual or to the family.

Needed for the understanding of the benefits.

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Needed for the understanding of the benefits.

Benefits Used to date.

Classification of benefit being provided.

Needed to convey the nature of the benefit.

For example: deductible, visits, benefit amount.

The quantity of the benefit which is permitted under the coverage.

Needed to convey the benefits offered under the coverage.

The quantity of the benefit which have been consumed to date.

Needed to convey the benefits consumed to date.