ExplanationOfBenefit
ExplanationOfBenefit
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.
Properties
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | No | Identifier[] | Business Identifier for the resource |
| status | Yes | code | active / cancelled / draft / entered-in-error |
| type | Yes | CodeableConcept | Category or discipline |
| subType | No | CodeableConcept | More granular claim type |
| use | Yes | code | claim / preauthorization / predetermination |
| patient | Yes | Reference<Patient> | The recipient of the products and services |
| billablePeriod | No | Period | Relevant time frame for the claim |
| created | Yes | dateTime | Response creation date |
| enterer | No | Reference<Practitioner / PractitionerRole> | Author of the claim |
| insurer | Yes | Reference<Organization> | Party responsible for reimbursement |
| provider | Yes | Reference<Practitioner / PractitionerRole / Organization> | Party responsible for the claim |
| priority | No | CodeableConcept | Desired processing urgency |
| fundsReserveRequested | No | CodeableConcept | For whom to reserve funds |
| fundsReserve | No | CodeableConcept | Funds reserved status |
| related | No | ExplanationOfBenefitRelated | Prior or corollary claims |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - claim | No | Reference<Claim> | Reference to the related claim |
| - relationship | No | CodeableConcept | How the reference claim is related |
| - reference | No | Identifier | File or case reference |
| prescription | No | Reference<MedicationRequest / VisionPrescription> | Prescription authorizing services or products |
| originalPrescription | No | Reference<MedicationRequest> | Original prescription if superceded by fulfiller |
| payee | No | ExplanationOfBenefitPayee | Recipient of benefits payable |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - type | No | CodeableConcept | Category of recipient |
| - party | No | Reference<Practitioner / PractitionerRole / Organization / Patient / RelatedPerson> | Recipient reference |
| referral | No | Reference<ServiceRequest> | Treatment Referral |
| facility | No | Reference<Location> | Servicing Facility |
| claim | No | Reference<Claim> | Claim reference |
| claimResponse | No | Reference<ClaimResponse> | Claim response reference |
| outcome | Yes | code | queued / complete / error / partial |
| disposition | No | string | Disposition Message |
| preAuthRef | No | string[] | Preauthorization reference |
| preAuthRefPeriod | No | Period[] | Preauthorization in-effect period |
| careTeam | No | ExplanationOfBenefitCareTeam | Care Team members |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Order of care team |
| - provider | Yes | Reference<Practitioner / PractitionerRole / Organization> | Practitioner or organization |
| - responsible | No | boolean | Indicator of the lead practitioner |
| - role | No | CodeableConcept | Function within the team |
| - qualification | No | CodeableConcept | Practitioner credential or specialization |
| supportingInfo | No | ExplanationOfBenefitSupportingInfo | Supporting information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Information instance identifier |
| - category | Yes | CodeableConcept | Classification of the supplied information |
| - code | No | CodeableConcept | Type of information |
| - timing[x] | No | date, Period | When it occurred |
| - value[x] | No | boolean, string, Quantity, Attachment, Reference<Resource> | Data to be provided |
| - reason | No | Coding | Explanation for the information |
| diagnosis | No | ExplanationOfBenefitDiagnosis | Pertinent diagnosis information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Diagnosis instance identifier |
| - diagnosis[x] | Yes | CodeableConcept, Reference<Condition> | Nature of illness or problem |
| - type | No | CodeableConcept[] | Timing or nature of the diagnosis |
| - onAdmission | No | CodeableConcept | Present on admission |
| - packageCode | No | CodeableConcept | Package billing code |
| procedure | No | ExplanationOfBenefitProcedure | Clinical procedures performed |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Procedure instance identifier |
| - type | No | CodeableConcept[] | Category of Procedure |
| - date | No | dateTime | When the procedure was performed |
| - procedure[x] | Yes | CodeableConcept, Reference<Procedure> | Specific clinical procedure |
| - udi | No | Reference<Device>[] | Unique device identifier |
| precedence | No | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | Yes | ExplanationOfBenefitInsurance | Patient insurance information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - focal | Yes | boolean | Coverage to be used for adjudication |
| - coverage | Yes | Reference<Coverage> | Insurance information |
| - preAuthRef | No | string[] | Prior authorization reference number |
| accident | No | ExplanationOfBenefitAccident | Details of the event |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - date | No | date | When the incident occurred |
| - type | No | CodeableConcept | The nature of the accident |
| - location[x] | No | Address, Reference<Location> | Where the event occurred |
| item | No | ExplanationOfBenefitItem | Product or service provided |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Item instance identifier |
| - careTeamSequence | No | positiveInt[] | Applicable care team members |
| - diagnosisSequence | No | positiveInt[] | Applicable diagnoses |
| - procedureSequence | No | positiveInt[] | Applicable procedures |
| - informationSequence | No | positiveInt[] | Applicable exception and supporting information |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Product or service billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - serviced[x] | No | date, Period | Date or dates of service or product delivery |
| - location[x] | No | CodeableConcept, Address, Reference<Location> | Place of service or where product was supplied |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| - bodySite | No | CodeableConcept | Anatomical location |
| - subSite | No | CodeableConcept[] | Anatomical sub-location |
| - encounter | No | Reference<Encounter>[] | Encounters related to this billed item |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | ExplanationOfBenefitItemAdjudication | Adjudication details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - category | Yes | CodeableConcept | Type of adjudication information |
| - reason | No | CodeableConcept | Explanation of adjudication outcome |
| - amount | No | Money | Monetary amount |
| - value | No | decimal | Non-monitary value |
| - detail | No | ExplanationOfBenefitItemDetail | Additional items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Product or service provided |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Detail level adjudication details |
| - subDetail | No | ExplanationOfBenefitItemDetailSubDetail | Additional items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Product or service provided |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Subdetail level adjudication details |
| addItem | No | ExplanationOfBenefitAddItem | Insurer added line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - itemSequence | No | positiveInt[] | Item sequence number |
| - detailSequence | No | positiveInt[] | Detail sequence number |
| - subDetailSequence | No | positiveInt[] | Subdetail sequence number |
| - provider | No | Reference<Practitioner / PractitionerRole / Organization>[] | Authorized providers |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - serviced[x] | No | date, Period | Date or dates of service or product delivery |
| - location[x] | No | CodeableConcept, Address, Reference<Location> | Place of service or where product was supplied |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - bodySite | No | CodeableConcept | Anatomical location |
| - subSite | No | CodeableConcept[] | Anatomical sub-location |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Added items adjudication |
| - detail | No | ExplanationOfBenefitAddItemDetail | Insurer added line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Added items adjudication |
| - subDetail | No | ExplanationOfBenefitAddItemDetailSubDetail | Insurer added line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Added items adjudication |
| adjudication | No | [] | Header-level adjudication |
| total | No | ExplanationOfBenefitTotal | Adjudication totals |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - category | Yes | CodeableConcept | Type of adjudication information |
| - amount | Yes | Money | Financial total for the category |
| payment | No | ExplanationOfBenefitPayment | Payment Details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - type | No | CodeableConcept | Partial or complete payment |
| - adjustment | No | Money | Payment adjustment for non-claim issues |
| - adjustmentReason | No | CodeableConcept | Explanation for the variance |
| - date | No | date | Expected date of payment |
| - amount | No | Money | Payable amount after adjustment |
| - identifier | No | Identifier | Business identifier for the payment |
| formCode | No | CodeableConcept | Printed form identifier |
| form | No | Attachment | Printed reference or actual form |
| processNote | No | ExplanationOfBenefitProcessNote | Note concerning adjudication |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - number | No | positiveInt | Note instance identifier |
| - type | No | code | display / print / printoper |
| - text | No | string | Note explanatory text |
| - language | No | CodeableConcept | Language of the text |
| benefitPeriod | No | Period | When the benefits are applicable |
| benefitBalance | No | ExplanationOfBenefitBenefitBalance | Balance by Benefit Category |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - category | Yes | CodeableConcept | Benefit classification |
| - excluded | No | boolean | Excluded from the plan |
| - name | No | string | Short name for the benefit |
| - description | No | string | Description of the benefit or services covered |
| - network | No | CodeableConcept | In or out of network |
| - unit | No | CodeableConcept | Individual or family |
| - term | No | CodeableConcept | Annual or lifetime |
| - financial | No | ExplanationOfBenefitBenefitBalanceFinancial | Benefit Summary |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - type | Yes | CodeableConcept | Benefit classification |
| - allowed[x] | No | unsignedInt, string, Money | Benefits allowed |
| - used[x] | No | unsignedInt, Money | Benefits used |
Search Parameters
| Name | Type | Description | Expression |
|---|---|---|---|
| care-team | reference | Member of the CareTeam | ExplanationOfBenefit.careTeam.provider |
| claim | reference | The reference to the claim | ExplanationOfBenefit.claim |
| coverage | reference | The plan under which the claim was adjudicated | ExplanationOfBenefit.insurance.coverage |
| created | date | The creation date for the EOB | ExplanationOfBenefit.created |
| detail-udi | reference | UDI associated with a line item detail product or service | ExplanationOfBenefit.item.detail.udi |
| disposition | string | The contents of the disposition message | ExplanationOfBenefit.disposition |
| encounter | reference | Encounters associated with a billed line item | ExplanationOfBenefit.item.encounter |
| enterer | reference | The party responsible for the entry of the Claim | ExplanationOfBenefit.enterer |
| facility | reference | Facility responsible for the goods and services | ExplanationOfBenefit.facility |
| identifier | token | The business identifier of the Explanation of Benefit | ExplanationOfBenefit.identifier |
| item-udi | reference | UDI associated with a line item product or service | ExplanationOfBenefit.item.udi |
| patient | reference | The reference to the patient | ExplanationOfBenefit.patient |
| payee | reference | The party receiving any payment for the Claim | ExplanationOfBenefit.payee.party |
| procedure-udi | reference | UDI associated with a procedure | ExplanationOfBenefit.procedure.udi |
| provider | reference | The reference to the provider | ExplanationOfBenefit.provider |
| status | token | Status of the instance | ExplanationOfBenefit.status |
| subdetail-udi | reference | UDI associated with a line item detail subdetail product or service | ExplanationOfBenefit.item.detail.subDetail.udi |
Inherited Properties
| Name | Required | Type | Description |
|---|---|---|---|
| id | No | string | Logical id of this artifact |
| meta | No | Meta | Metadata about the resource |
| implicitRules | No | uri | A set of rules under which this content was created |
| language | No | code | Language of the resource content |
| text | No | Narrative | Text summary of the resource, for human interpretation |
| contained | No | Resource[] | Contained, inline Resources |
| extension | No | Extension[] | Additional content defined by implementations |
| modifierExtension | No | Extension[] | Extensions that cannot be ignored |
To view the FHIR specification for this resource, see ExplanationOfBenefit.