Release 4 FHIR CI-Build

This page is part of the Continuous Integration Build of FHIR Specification (v4.0.1: R4 - Mixed Normative and STU ) in it's permanent home (it will always (will be available incorrect/inconsistent at this URL). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see times).
See the Directory of published versions icon . Page versions: R5 R4B R4 R3 R2

13.10 Resource ExplanationOfBenefit - Content

Responsible Owner: Financial Management icon Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

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

13.10.1 Scope and Usage

The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.

This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information in respect of a single payor payer 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 payer which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.

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

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

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

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

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

13.10.1.1 Additional Information

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

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

13.10.2 Boundaries and Relationships

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

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

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

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

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

13.10.3 References to this Resource

  • Implements: Event
  • Resource References: itself

13.10.3 13.10.4 Resource Content

Structure

1..1 1..1 BackboneElement BackboneElement value[x] 0..1 Data to be provided valueBoolean boolean valueString string 1..* BackboneElement 1..1 CodeableConcept Anatomical sub-location BackboneElement 0..1 1..1 see 0..1 1..1 CodeableConcept Anatomical sub-location see see 0..1 see display | print | printoper
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . ExplanationOfBenefit TU DomainResource Explanation of Benefit resource

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

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus Binding: Explanation Of Benefit Status ( Required )
. . . statusReason Σ 0..1 string Reason for status change
. . . type Σ 1..1 CodeableConcept Category or discipline
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient subject Σ 1..1 Reference ( Patient | Group ) The recipient recipient(s) of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Response creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Party responsible for reimbursement
. . . provider Σ 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority 0..1 CodeableConcept Desired processing urgency
ProcessPriority Binding: Process Priority Codes ( Example Preferred )
. . . fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
FundsReserve Binding: Funds Reservation Codes ( Example Preferred )
. . . fundsReserve 0..1 CodeableConcept Funds reserved status
FundsReserve Binding: Funds Reservation Codes ( Example Preferred )
. . . related 0..* BackboneElement Prior or corollary claims

. . . . claim 0..1 Reference ( Claim | ExplanationOfBenefit ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Binding: Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription ) Prescription authorizing services or products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription ) Original prescription if superceded by fulfiller
. . . payee event 0..* BackboneElement Event information

0..1
. . . . type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 0..1 CodeableConcept Category of recipient
PayeeType Binding: Claim Payee Type Codes ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment Referral
. . facility . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

0..1
. . . facility 0..1 Reference ( Location | Organization ) Servicing Facility
. . . claim 0..1 Reference ( Claim ) Claim reference
. . . claimResponse 0..1 Reference ( ClaimResponse ) Claim response reference
. . . outcome Σ 1..1 code queued | complete | error | partial
Binding: Claim Processing Codes ( Required )
. . disposition . decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Preferred )
... disposition 0..1 string Disposition Message
. . . preAuthRef 0..* string Preauthorization reference

. . . preAuthRefPeriod 0..* Period Preauthorization in-effect period

. . careTeam . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
0..*
. . . careTeam 0..* BackboneElement Care Team members

. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization responsible 0..1 boolean
Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Binding: Claim Care Team Role Codes ( Example Preferred )
. . . qualification . specialty 0..1 CodeableConcept Practitioner credential or provider specialization
Binding: Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information

. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept Classification of the supplied information
Binding: Claim Information Category Codes ( Example Preferred )
. . . . code 0..1 CodeableConcept Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . timingDate . timingDateTime date dateTime
. . . . . timingPeriod Period
. . . . . valueQuantity timingTiming Quantity Timing
. . . . valueAttachment Attachment value[x] valueReference 0..1 Reference ( Any * ) Data to be provided
. . . . reason 0..1 Coding Explanation for the information
Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information

. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes ( Example Preferred )

. . . . onAdmission 0..1 CodeableConcept Present on admission
Binding: Example Diagnosis on Admission Codes ( Example Preferred ) packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
. . . procedure 0..* BackboneElement Clinical procedures performed

. . . . sequence 1..1 positiveInt Procedure instance identifier
. . . . type 0..* CodeableConcept Category of Procedure
Binding: Example Procedure Type Codes ( Example Preferred )

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
. . . insurance Σ 0..* BackboneElement Patient insurance information

. . . . focal Σ 1..1 boolean Coverage to be used for adjudication
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . preAuthRef 0..* string Prior authorization reference number

. . . accident 0..1 BackboneElement Details of the event
. . . . date 0..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . item . patientPaid 0..1 Money Paid by the patient
0..*
. . . item 0..* BackboneElement Product or service provided

. . . . sequence 1..1 positiveInt Item instance identifier
. . . . careTeamSequence 0..* positiveInt Applicable care team members

. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses

. . . . procedureSequence 0..* positiveInt Applicable procedures

. . . . informationSequence 0..* positiveInt Applicable exception and supporting information

. . . revenue . traceNumber 0..* Identifier Number for tracking

. . . . subject 0..1 Reference ( Patient | Group ) The recipient of the products and services
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . modifier . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . patientPaid 0..1 Money Paid by the patient
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total tax
0..1
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . bodySite 0..* BackboneElement Anatomical location

0..1
. . . . . site Anatomical location 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item associated with the listed treatments

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 0..1 BackboneElement Adjudication results
. . . . . decision 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Preferred )
..... reason 0..* CodeableConcept BackboneElement Reason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes ( Example )

. . . . . preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* BackboneElement Adjudication details

. . . . . category 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example Preferred )
. . . . . reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . value . quantity 0..1 decimal Quantity Non-monitary value
. . . . detail . decisionDate 0..1 dateTime When was adjudication performed
0..*
. . . . detail 0..* BackboneElement Additional items

. . . . . sequence 1..1 positiveInt Product or service provided
. . . . . revenue traceNumber 0..* Identifier Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . . quantity patientPaid 0..1 Money Paid by the patient
0..1
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . net . tax 0..1 Money Total tax
0..1
. . . . . net 0..1 Money Total item cost
. . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 0..1 see reviewOutcome Detail level adjudication results
0..*
. . . . . adjudication 0..* see adjudication Detail level adjudication details

. . . . . subDetail 0..* BackboneElement Additional items

. . . . . . sequence 1..1 positiveInt Product or service provided
. . . . . revenue . traceNumber 0..* Identifier Number for tracking

. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
0..*
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . . quantity . patientPaid 0..1 Money Paid by the patient
0..1
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total tax
0..1
. . . . . . net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details

. . . addItem 0..* BackboneElement Insurer added line items

. . . . itemSequence 0..* positiveInt Item sequence number

. . . . detailSequence 0..* positiveInt Detail sequence number

. . . . subDetailSequence 0..* positiveInt Subdetail sequence number

. . . provider . traceNumber 0..* Identifier Number for tracking

. . . . subject 0..1 Reference ( Patient | Group ) The recipient of the products and services
.... informationSequence 0..* positiveInt Applicable exception and supporting information

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

. . . productOrService . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
1..1
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . modifier . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . patientPaid 0..1 Money Paid by the patient
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total item cost tax
. . . . bodySite net 0..1 Money Total item cost
0..1
. . . . bodySite 0..* BackboneElement Anatomical location

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

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem level adjudication results
0..*
. . . . adjudication 0..* see adjudication Added items adjudication

. . . . detail 0..* BackboneElement Insurer added line items

. . . . productOrService . traceNumber 0..* Identifier Number for tracking

1..1
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . quantity patientPaid 0..1 Money Paid by the patient
0..1
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . net . tax 0..1 Money Total tax
0..1
. . . . . net 0..1 Money Total item cost
. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem detail level adjudication results
0..*
. . . . . adjudication 0..* see adjudication Added items adjudication

. . . . . subDetail 0..* BackboneElement Insurer added line items

. . . . . productOrService . traceNumber 0..* Identifier Number for tracking

1..1
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . quantity patientPaid 0..1 Money Paid by the patient
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . net . tax 0..1 Money Total tax
0..1
. . . . . . net 0..1 Money Total item cost
. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem subdetail level adjudication results
0..*
. . . . . . adjudication 0..* see adjudication Added items adjudication

. . . adjudication 0..* see adjudication Header-level adjudication

. . . total Σ 0..* BackboneElement Adjudication totals

. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Financial total for the category
. . . payment 0..1 BackboneElement Payment Details
. . . . type 0..1 CodeableConcept Partial or complete payment
Binding: Example Payment Type Codes ( Example Preferred )
. . . . adjustment 0..1 Money Payment adjustment for non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: Payment Adjustment Reason Codes ( Example Preferred )
. . . . date 0..1 date Expected date of payment
. . . . amount 0..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment
. . . formCode 0..1 CodeableConcept Printed form identifier
Forms Binding: Form Codes ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Note concerning adjudication

. . . number . class 0..1 CodeableConcept Business kind of note
Binding: ProcessNoteClass ( Example )
0..1
. . . . number 0..1 positiveInt Note instance identifier
. . . . type 0..1 code CodeableConcept Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 0..1 string markdown Note explanatory text
. . . . language 0..1 CodeableConcept Language of the text
Common Binding: All Languages ( Preferred but limited to AllLanguages Required )
Additional Bindings Purpose
Common Languages Starter

. . . benefitPeriod 0..1 Period When the benefits are applicable
. . . benefitBalance 0..* BackboneElement Balance by Benefit Category

. . . . category 1..1 CodeableConcept Benefit classification
Binding: Benefit Category 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
Binding: Network Type Codes ( Example )
. . . . unit 0..1 CodeableConcept Individual or family
Binding: Unit Type Codes ( Example )
. . . . term 0..1 CodeableConcept Annual or lifetime
Binding: Benefit Term Codes ( Example )
. . . . financial 0..* BackboneElement Benefit Summary

. . . . . type 1..1 CodeableConcept Benefit classification
Binding: 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

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

ExplanationOfBenefit ( DomainResource ) A unique identifier assigned to this explanation of benefit identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) ExplanationOfBenefitStatus ! » Used to indicate why the status has changed statusReason : string [0..1] The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services which could under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « Complete, proposed, exploratory, other. null (Strength=Required) Use ! » The party party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought patient subject : Reference [1..1] « Patient | Group » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The party responsible for authorization, adjudication and reimbursement insurer : Reference [1..1] [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization provider : Reference [1..1] [0..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine normal deferred priority : CodeableConcept [0..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example) null (Strength=Preferred) ProcessPriority ProcessPriorityCodes ?? ? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserveRequested : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) null (Strength=Preferred) Funds Reservation ?? FundsReservationCodes ? » A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) null (Strength=Preferred) Funds Reservation FundsReservationCodes ?? ? » Prescription is the document/authorization given to support the dispensing of pharmacy, device or vision claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments prescription : Reference [0..1] « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » A reference The referral information received by the claim author, it is not to be used when the author generates a referral resource for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] « ServiceRequest » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » Facility where the services were provided facility : Reference [0..1] « Location | Organization » The business identifier for the instance of the adjudication request: claim predetermination or preauthorization claim : Reference [0..1] « Claim » The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response claimResponse : Reference [0..1] « ClaimResponse » The outcome of the claim, predetermination, or preauthorization processing outcome : code [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing. (Strength=Required) claim, predetermination, or preauthorization adjudication ClaimProcessingCodes ! decision : CodeableConcept [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..*] The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided preAuthRefPeriod : Period [0..*] A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » This indicates the relative order of a series of EOBs related to different coverages for the same suite of services precedence : positiveInt [0..1] The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] A code for the form to be used for printing the content formCode : CodeableConcept [0..1] « The forms codes. null (Strength=Example) Form FormCodes ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] The term of the benefits documented in this response benefitPeriod : Period [0..1] RelatedClaim Reference to a related Claim or ExplanationOfBenefit as a representation of a claim claim : Reference [0..1] « Claim | ExplanationOfBenefit » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. null (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » Payee Type of Party to be reimbursed: Subscriber, billing provider, other type : CodeableConcept [0..1] « A code for the party to be reimbursed. null (Strength=Example) Claim Payee Type ClaimPayeeTypeCodes ?? » Reference to the individual or organization to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) null (Strength=Preferred) ClaimCareTeamRoleCodes ?? ? » The qualification specialization of the practitioner or provider which is applicable for this service qualification specialty : CodeableConcept [0..1] « Provider professional qualifications. null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example) null (Strength=Preferred) ClaimInformationCategoryCodes ?? ? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [0..1] « date dateTime | Period | Timing » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type * [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » Provides the reason in the situation where a reason code is required in addition to the content reason : Coding [0..1] « Reason codes for the missing teeth. null (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. null (Strength=Example) ICD-10Codes ICD10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example) null (Strength=Preferred) ExampleDiagnosisTypeCodes ?? ? » Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » 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 packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) null (Strength=Preferred) ExampleDiagnosisRelatedGroupC... ExampleDiagnosisOnAdmissionCo... ?? ? » Procedure A number to uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example) null (Strength=Preferred) ExampleProcedureTypeCodes ?? ? » Date and optionally time the procedure was performed date : dateTime [0..1] The code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); ICD10 Procedure codes. null (Strength=Example) ICD-10ProcedureCodes ICD10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] Accident Date of an accident event related to the products and services contained in the claim date : date [0..1] The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. null (Strength=Extensible) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] Care team members related to this service or product careTeamSequence : positiveInt [0..*] Diagnoses applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought subject : Reference [0..1] « Patient | Group » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place where the service is rendered. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] ItemBodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » ReviewOutcome A billed item may include goods The result of the claim, predetermination, or services provided in multiple encounters preauthorization adjudication encounter decision : Reference CodeableConcept [0..*] [0..1] « Encounter null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » The numbers associated with notes below reasons for the result of the claim, predetermination, or preauthorization adjudication reason : CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which apply is used in later communications which refers to the this adjudication of preAuthRef : string [0..1] The time frame during which this item authorization is effective noteNumber preAuthPeriod : positiveInt Period [0..*] [0..1] Adjudication 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 category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) null (Strength=Preferred) AdjudicationValueCodes ?? ? » A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « Adjudication reason codes. null (Strength=Example) AdjudicationReasonCodes ?? » Monetary amount associated with the category amount : Money [0..1] A non-monetary value associated with the category. Mutually exclusive to the amount element above value quantity : decimal Quantity [0..1] The date and time the adjudication decision occured decisionDate : dateTime [0..1] Detail A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the details within the claim item which this line is intended to replace detailSequence : positiveInt [0..*] The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace subDetailSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought subject : Reference [0..1] « Patient | Group » Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The providers who are authorized for the services rendered to the patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place where the service is rendered. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemBodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » AddedItemDetail The numbers associated with notes below which apply to Trace number for tracking purposes. May be defined at the adjudication of this item jurisdiction level or between trading partners noteNumber traceNumber : positiveInt Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « AddedItemDetail null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemDetailSubDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Total 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » Monetary total amount associated with the category amount : Money [1..1] Payment Whether this represents partial or complete payment of the benefits payable type : CodeableConcept [0..1] « The type (partial, complete) of the payment. (Strength=Example) null (Strength=Preferred) ExamplePaymentTypeCodes ?? ? » Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) null (Strength=Preferred) PaymentAdjustmentReasonCodes ?? ? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Benefits payable less any payment adjustment amount : Money [0..1] Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note A code to indicate the business purpose of the note class : CodeableConcept [0..1] « null (Strength=Example) ProcessNoteClass?? » A number to uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note text type : code CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The explanation or description associated with the processing text : string markdown [0..1] A code to define the language used in the text of the note language : CodeableConcept [0..1] « A human language. (Strength=Preferred) null (Strength=Required) CommonLanguages ? AllLanguages ! » BenefitBalance Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit name : string [0..1] A richer description of the benefit or services covered description : string [0..1] Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers network : CodeableConcept [0..1] « Code to classify in or out of network services. null (Strength=Example) NetworkTypeCodes ?? » Indicates if the benefits apply to an individual or to the family unit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. null (Strength=Example) UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. null (Strength=Example) BenefitTermCodes ?? » Benefit Classification of benefit being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. null (Strength=Example) BenefitTypeCodes ?? » The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » The quantity of the benefit which have been consumed to date used[x] : Type DataType [0..1] « unsignedInt | Money » Other claims which are related to this claim such as prior submissions or claims for related services or for the same event related [0..*] Information code for an event with a corresponding date or period event [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] The members of the team who provided the products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] [0..*] Details of a accident which resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] 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 adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] Third-tier of goods and services subDetail [0..*] Second-tier of goods and services detail [0..*] A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details item [0..*] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The third-tier service adjudications for payor payer added services subDetail [0..*] The second-tier service adjudications for payor payer added services detail [0..*] The first-tier service adjudications for payor payer added product or service lines addItem [0..*] The adjudication results which are presented at the header level rather than at the line-item or add-item levels adjudication [0..*] Categorized monetary totals for the adjudication total [0..*] Payment details for the adjudication of the claim payment [0..1] A note that describes or explains adjudication results in a human readable form processNote [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template 

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for the resource --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <statusReason value="[string]"/><!-- 0..1 Reason for status change -->

 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <
 <</patient>

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <subject><!-- 1..1 Reference(Group|Patient) The recipient(s) of the products and services --></subject>

 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <</enterer>
 <</insurer>
 <</provider>
 <</priority>

 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>

 <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <</claim>

  <claim><!-- 0..1 Reference(Claim|ExplanationOfBenefit) Reference to the related claim --></claim>

  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <</prescription>
 <</originalPrescription>

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|ServiceRequest|
   VisionPrescription) Prescription authorizing services or products --></prescription>

 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   ServiceRequest|VisionPrescription) Original prescription if superceded by fulfiller --></originalPrescription>

 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <</type>
  <|

  <type><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>

 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <

 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference -->
 <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>

 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <</provider>
  <

  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>

  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <</qualification>

  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <</timing[x]>
  <</value[x]>

  <timing[x]><!-- 0..1 dateTime|Period|Timing When it occurred --></timing[x]>
  <value[x]><!-- 0..1 * Data to be provided --></value[x]>

  <reason><!-- 0..1 Coding Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <</packageCode>

 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <

 <insurance>  <!-- 0..* Patient insurance information -->

  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <subject><!-- 0..1 Reference(Group|Patient) The recipient of the products and services --></subject>

  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <</productOrService>

  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>

  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <</bodySite>
  <</subSite>
  <</encounter>

  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>

  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <quantity><!-- 0..1 Quantity Non-monitary value --></quantity>
   <decisionDate value="[dateTime]"/><!-- 0..1 When was adjudication performed -->

  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <</productOrService>

   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Detail level adjudication results --></reviewOutcome>

   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <</productOrService>

    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <

 <addItem>  <!-- 0..* Insurer added line items -->

  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <</provider>
  <</productOrService>

  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <subject><!-- 0..1 Reference(Group|Patient) The recipient of the products and services --></subject>
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</bodySite>
  <</subSite>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem level adjudication results --></reviewOutcome>

  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <
   <</productOrService>

  <detail>  <!-- 0..* Insurer added line items -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem detail level adjudication results --></reviewOutcome>

   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <
    <</productOrService>

   <subDetail>  <!-- 0..* Insurer added line items -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <class><!-- 0..1 CodeableConcept Business kind of note --></class>

  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <
  <
  <</language>

  <type><!-- 0..1 CodeableConcept Note purpose --></type>
  <text value="[markdown]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit classification --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Benefit classification --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template 

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for the resource
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "statusReason" : "<string>", // Reason for status change

  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "subject" : { Reference(Group|Patient) }, // R!  The recipient(s) of the products and services

  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Response creation date
  "
  "
  "
  "

  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency

  "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "related" : [{ // Prior or corollary claims
    "

    "claim" : { Reference(Claim|ExplanationOfBenefit) }, // Reference to the related claim

    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "
  "

  "prescription" : { Reference(DeviceRequest|MedicationRequest|ServiceRequest|
   VisionPrescription) }, // Prescription authorizing services or products

  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   ServiceRequest|VisionPrescription) }, // Original prescription if superceded by fulfiller

  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "payee" : { // Recipient of benefits payable
    "
    "|

    "type" : { CodeableConcept }, // Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) } // Recipient reference
  },
  "
  "

  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing Facility

  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "

  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication

  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : ["<string>"], // Preauthorization reference
  "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code

  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Order of care team
    "
    "

    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization

    "role" : { CodeableConcept }, // Function within the team
    "

    "specialty" : { CodeableConcept } // Practitioner or provider specialization

  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    
    ">",

    // timing[x]: When it occurred. One of these 3:
    "timingDateTime" : "<dateTime>",

    "timingPeriod" : { Period },
    

    "timingTiming" : { Timing },
    // value[x]: Data to be provided. One of these 55:

    "valueBase64Binary" : "<base64Binary>",

    "valueBoolean" : <boolean>,
    "valueCanonical" : "<canonical>",
    "valueCode" : "<code>",
    "valueDate" : "<date>",
    "valueDateTime" : "<dateTime>",
    "valueDecimal" : <decimal>,
    "valueId" : "<id>",
    "valueInstant" : "<instant>",
    "valueInteger" : <integer>,
    "valueInteger64" : "<integer64>",
    "valueMarkdown" : "<markdown>",
    "valueOid" : "<oid>",
    "valuePositiveInt" : "<positiveInt>",

    "valueString" : "<string>",
    " },

    "valueTime" : "<time>",
    "valueUnsignedInt" : "<unsignedInt>",
    "valueUri" : "<uri>",
    "valueUrl" : "<url>",
    "valueUuid" : "<uuid>",
    "valueAddress" : { Address },
    "valueAge" : { Age },
    "valueAnnotation" : { Annotation },

    "valueAttachment" : { Attachment },
    " },

    "valueCodeableConcept" : { CodeableConcept },
    "valueCodeableReference" : { CodeableReference },
    "valueCoding" : { Coding },
    "valueContactPoint" : { ContactPoint },
    "valueCount" : { Count },
    "valueDistance" : { Distance },
    "valueDuration" : { Duration },
    "valueHumanName" : { HumanName },
    "valueIdentifier" : { Identifier },
    "valueMoney" : { Money },
    "valuePeriod" : { Period },
    "valueQuantity" : { Quantity },
    "valueRange" : { Range },
    "valueRatio" : { Ratio },
    "valueRatioRange" : { RatioRange },
    "valueReference" : { Reference },
    "valueSampledData" : { SampledData },
    "valueSignature" : { Signature },
    "valueTiming" : { Timing },
    "valueContactDetail" : { ContactDetail },
    "valueDataRequirement" : { DataRequirement },
    "valueExpression" : { Expression },
    "valueParameterDefinition" : { ParameterDefinition },
    "valueRelatedArtifact" : { RelatedArtifact },
    "valueTriggerDefinition" : { TriggerDefinition },
    "valueUsageContext" : { UsageContext },
    "valueAvailability" : { Availability },
    "valueExtendedContactDetail" : { ExtendedContactDetail },
    "valueVirtualServiceDetail" : { VirtualServiceDetail },
    "valueDosage" : { Dosage },
    "valueMeta" : { Meta },

    "reason" : { Coding } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "
    "

    "onAdmission" : { CodeableConcept } // Present on admission

  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "

  "insurance" : [{ // Patient insurance information

    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "preAuthRef" : ["<string>"] // Prior authorization reference number
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // When the incident occurred
    "

    "type" : { CodeableConcept }, // The nature of the accident icon

    // location[x]: Where the event occurred. One of these 2:
    " }

    "locationAddress" : { Address },

    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable care team members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "traceNumber" : [{ Identifier }], // Number for tracking
    "subject" : { Reference(Group|Patient) }, // The recipient of the products and services

    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "

    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost

    "udi" : [{ Reference(Device) }], // Unique device identifier
    "
    "
    "

    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },

    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "

      "quantity" : { Quantity }, // Non-monitary value
      "decisionDate" : "<dateTime>" // When was adjudication performed

    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Product or service provided
      "traceNumber" : [{ Identifier }], // Number for tracking

      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "

      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "udi" : [{ Reference(Device) }], // Unique device identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Detail level adjudication results

      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Product or service provided
        "traceNumber" : [{ Identifier }], // Number for tracking

        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "

        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "udi" : [{ Reference(Device) }], // Unique device identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Subdetail level adjudication results

        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "

  "addItem" : [{ // Insurer added line items

    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "
    "

    "traceNumber" : [{ Identifier }], // Number for tracking
    "subject" : { Reference(Group|Patient) }, // The recipient of the products and services
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "
    "
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem level adjudication results

    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "
      "

    "detail" : [{ // Insurer added line items
      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem detail level adjudication results

      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "
        "

      "subDetail" : [{ // Insurer added line items
        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem subdetail level adjudication results

        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the variance
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "class" : { CodeableConcept }, // Business kind of note

    "number" : "<positiveInt>", // Note instance identifier
    "
    "
    "

    "type" : { CodeableConcept }, // Note purpose
    "text" : "<markdown>", // Note explanatory text
    "language" : { CodeableConcept } // Language of the text

  }],
  "benefitPeriod" : { Period }, // When the benefits are applicable
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit classification
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Benefit classification
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      ">"

      "usedUnsignedInt" : "<unsignedInt>",

      "usedMoney" : { Money }
    }]
  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
    ], ...;
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      # . One of these 3
        fhir: ]
        fhir: ]
        fhir: ]
      # . One of these 2
        fhir: ]
        fhir: ]
    ], ...;
  ], ...;

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for the resource
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:statusReason [ string ] ; # 0..1 Reason for status change
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 The recipient(s) of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Response creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserveRequested [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim|ExplanationOfBenefit) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|ServiceRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services or products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|ServiceRequest|VisionPrescription) ] ; # 0..1 Original prescription if superceded by fulfiller
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:DateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 0..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment Referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing Facility
  fhir:claim [ Reference(Claim) ] ; # 0..1 Claim reference
  fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Claim response reference
  fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial
  fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
  fhir:disposition [ string ] ; # 0..1 Disposition Message
  fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Preauthorization reference
  fhir:preAuthRefPeriod  ( [ Period ] ... ) ; # 0..* Preauthorization in-effect period
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:careTeam ( [ # 0..* Care Team members
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 3
      fhir:timing [  a fhir:DateTime ; dateTime ]
      fhir:timing [  a fhir:Period ; Period ]
      fhir:timing [  a fhir:Timing ; Timing ]
    # value[x] : 0..1 Data to be provided. One of these 55
      fhir:value [  a fhir:Base64Binary ; base64Binary ]
      fhir:value [  a fhir:Boolean ; boolean ]
      fhir:value [  a fhir:Canonical ; canonical ]
      fhir:value [  a fhir:Code ; code ]
      fhir:value [  a fhir:Date ; date ]
      fhir:value [  a fhir:DateTime ; dateTime ]
      fhir:value [  a fhir:Decimal ; decimal ]
      fhir:value [  a fhir:Id ; id ]
      fhir:value [  a fhir:Instant ; instant ]
      fhir:value [  a fhir:Integer ; integer ]
      fhir:value [  a fhir:Integer64 ; integer64 ]
      fhir:value [  a fhir:Markdown ; markdown ]
      fhir:value [  a fhir:Oid ; oid ]
      fhir:value [  a fhir:PositiveInt ; positiveInt ]
      fhir:value [  a fhir:String ; string ]
      fhir:value [  a fhir:Time ; time ]
      fhir:value [  a fhir:UnsignedInt ; unsignedInt ]
      fhir:value [  a fhir:Uri ; uri ]
      fhir:value [  a fhir:Url ; url ]
      fhir:value [  a fhir:Uuid ; uuid ]
      fhir:value [  a fhir:Address ; Address ]
      fhir:value [  a fhir:Age ; Age ]
      fhir:value [  a fhir:Annotation ; Annotation ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:value [  a fhir:CodeableReference ; CodeableReference ]
      fhir:value [  a fhir:Coding ; Coding ]
      fhir:value [  a fhir:ContactPoint ; ContactPoint ]
      fhir:value [  a fhir:Count ; Count ]
      fhir:value [  a fhir:Distance ; Distance ]
      fhir:value [  a fhir:Duration ; Duration ]
      fhir:value [  a fhir:HumanName ; HumanName ]
      fhir:value [  a fhir:Identifier ; Identifier ]
      fhir:value [  a fhir:Money ; Money ]
      fhir:value [  a fhir:Period ; Period ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Range ; Range ]
      fhir:value [  a fhir:Ratio ; Ratio ]
      fhir:value [  a fhir:RatioRange ; RatioRange ]
      fhir:value [  a fhir:Reference ; Reference ]
      fhir:value [  a fhir:SampledData ; SampledData ]
      fhir:value [  a fhir:Signature ; Signature ]
      fhir:value [  a fhir:Timing ; Timing ]
      fhir:value [  a fhir:ContactDetail ; ContactDetail ]
      fhir:value [  a fhir:DataRequirement ; DataRequirement ]
      fhir:value [  a fhir:Expression ; Expression ]
      fhir:value [  a fhir:ParameterDefinition ; ParameterDefinition ]
      fhir:value [  a fhir:RelatedArtifact ; RelatedArtifact ]
      fhir:value [  a fhir:TriggerDefinition ; TriggerDefinition ]
      fhir:value [  a fhir:UsageContext ; UsageContext ]
      fhir:value [  a fhir:Availability ; Availability ]
      fhir:value [  a fhir:ExtendedContactDetail ; ExtendedContactDetail ]
      fhir:value [  a fhir:VirtualServiceDetail ; VirtualServiceDetail ]
      fhir:value [  a fhir:Dosage ; Dosage ]
      fhir:value [  a fhir:Meta ; Meta ]
    fhir:reason [ Coding ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:precedence [ positiveInt ] ; # 0..1 Precedence (primary, secondary, etc.)
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 0..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable care team members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:subject [ Reference(Group|Patient) ] ; # 0..1 The recipient of the products and services
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:Date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ # 0..1 Adjudication results
      fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
      fhir:reason  ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication
      fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
      fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
    ] ;
    fhir:adjudication ( [ # 0..* Adjudication details
      fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
      fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome
      fhir:amount [ Money ] ; # 0..1 Monetary amount
      fhir:quantity [ Quantity ] ; # 0..1 Non-monitary value
      fhir:decisionDate [ dateTime ] ; # 0..1 When was adjudication performed
    ] ... ) ;
    fhir:detail ( [ # 0..* Additional items
      fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Detail level adjudication results
      fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Detail level adjudication details
      fhir:subDetail ( [ # 0..* Additional items
        fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results
        fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:addItem ( [ # 0..* Insurer added line items
    fhir:itemSequence  ( [ positiveInt ] ... ) ; # 0..* Item sequence number
    fhir:detailSequence  ( [ positiveInt ] ... ) ; # 0..* Detail sequence number
    fhir:subDetailSequence  ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:subject [ Reference(Group|Patient) ] ; # 0..1 The recipient of the products and services
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:provider  ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:Date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem level adjudication results
    fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
    fhir:detail ( [ # 0..* Insurer added line items
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem detail level adjudication results
      fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
      fhir:subDetail ( [ # 0..* Insurer added line items
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem subdetail level adjudication results
        fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Header-level adjudication
  fhir:total ( [ # 0..* Adjudication totals
    fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
    fhir:amount [ Money ] ; # 1..1 Financial total for the category
  ] ... ) ;
  fhir:payment [ # 0..1 Payment Details
    fhir:type [ CodeableConcept ] ; # 0..1 Partial or complete payment
    fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues
    fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the variance
    fhir:date [ date ] ; # 0..1 Expected date of payment
    fhir:amount [ Money ] ; # 0..1 Payable amount after adjustment
    fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment
  ] ;
  fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier
  fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form
  fhir:processNote ( [ # 0..* Note concerning adjudication
    fhir:class [ CodeableConcept ] ; # 0..1 Business kind of note
    fhir:number [ positiveInt ] ; # 0..1 Note instance identifier
    fhir:type [ CodeableConcept ] ; # 0..1 Note purpose
    fhir:text [ markdown ] ; # 0..1 Note explanatory text
    fhir:language [ CodeableConcept ] ; # 0..1 Language of the text
  ] ... ) ;
  fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable
  fhir:benefitBalance ( [ # 0..* Balance by Benefit Category
    fhir:category [ CodeableConcept ] ; # 1..1 Benefit classification
    fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan
    fhir:name [ string ] ; # 0..1 Short name for the benefit
    fhir:description [ string ] ; # 0..1 Description of the benefit or services covered
    fhir:network [ CodeableConcept ] ; # 0..1 In or out of network
    fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family
    fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime
    fhir:financial ( [ # 0..* Benefit Summary
      fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification
      # allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:allowed [  a fhir:UnsignedInt ; unsignedInt ]
        fhir:allowed [  a fhir:String ; string ]
        fhir:allowed [  a fhir:Money ; Money ]
      # used[x] : 0..1 Benefits used. One of these 2
        fhir:used [  a fhir:UnsignedInt ; unsignedInt ]
        fhir:used [  a fhir:Money ; Money ]
    ] ... ) ;
  ] ... ) ;

]

Changes since R3 from both R4 and R4B

ExplanationOfBenefit.addItem.detail.net Renamed from fee to net
ExplanationOfBenefit
ExplanationOfBenefit.status ExplanationOfBenefit.traceNumber
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/explanationofbenefit-status to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 Added Element
ExplanationOfBenefit.type ExplanationOfBenefit.statusReason
  • Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Added Element
ExplanationOfBenefit.subType ExplanationOfBenefit.subject
  • Max Cardinality changed from * to 1 Added Mandatory Element
ExplanationOfBenefit.use ExplanationOfBenefit.enterer
  • Type Reference: Added Mandatory Element Target Types Patient, RelatedPerson
ExplanationOfBenefit.patient ExplanationOfBenefit.insurer
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.created ExplanationOfBenefit.provider
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.enterer ExplanationOfBenefit.related.claim
  • Type Reference: Added Target Type PractitionerRole ExplanationOfBenefit
ExplanationOfBenefit.insurer ExplanationOfBenefit.prescription
  • Min Cardinality changed from 0 to 1 Type Reference: Added Target Types DeviceRequest, ServiceRequest
ExplanationOfBenefit.provider ExplanationOfBenefit.originalPrescription
    Min Cardinality changed from 0 to 1
  • Type Reference: Added Target Types PractitionerRole, Organization DeviceRequest, ServiceRequest, VisionPrescription
ExplanationOfBenefit.priority ExplanationOfBenefit.event
  • Added Element
ExplanationOfBenefit.fundsReserveRequested ExplanationOfBenefit.event.type
  • Added Mandatory Element
ExplanationOfBenefit.fundsReserve ExplanationOfBenefit.event.when[x]
  • Added Mandatory Element
ExplanationOfBenefit.payee.party ExplanationOfBenefit.encounter
  • Type Reference: Added Target Type PractitionerRole Element
ExplanationOfBenefit.referral ExplanationOfBenefit.facility
  • Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Organization
ExplanationOfBenefit.outcome
  • Min Cardinality changed from 0 to 1 Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to code Claim Processing Codes
ExplanationOfBenefit.decision
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required) Added Element
ExplanationOfBenefit.preAuthRef ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.preAuthRefPeriod ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.careTeam.provider ExplanationOfBenefit.supportingInfo.timing[x]
  • Add Types dateTime, Timing
  • Remove Type Reference: Added Target Type PractitionerRole date
ExplanationOfBenefit.supportingInfo ExplanationOfBenefit.supportingInfo.value[x]
  • Renamed from information to supportingInfo Add Types base64Binary, canonical, code, date, dateTime, decimal, id, instant, integer, integer64, markdown, oid, positiveInt, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, CodeableConcept, CodeableReference, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Range, Ratio, RatioRange, SampledData, Signature, Timing, ContactDetail, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Availability, ExtendedContactDetail, VirtualServiceDetail, Dosage, Meta
ExplanationOfBenefit.supportingInfo.sequence ExplanationOfBenefit.insurance
  • Moved Min Cardinality changed from ExplanationOfBenefit.information 1 to ExplanationOfBenefit.supportingInfo 0
ExplanationOfBenefit.supportingInfo.category ExplanationOfBenefit.patientPaid
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.code ExplanationOfBenefit.item.traceNumber
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.timing[x] ExplanationOfBenefit.item.subject
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.value[x] ExplanationOfBenefit.item.productOrService
  • Moved Min Cardinality changed from ExplanationOfBenefit.information 1 to ExplanationOfBenefit.supportingInfo Add Type boolean 0
ExplanationOfBenefit.supportingInfo.reason ExplanationOfBenefit.item.productOrServiceEnd
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.diagnosis.onAdmission ExplanationOfBenefit.item.request
  • Added Element
ExplanationOfBenefit.procedure.type ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.procedure.udi ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.insurance ExplanationOfBenefit.item.bodySite
  • Min Max Cardinality changed from 0 to 1 to *
  • Max Cardinality Type changed from 1 CodeableConcept to * BackboneElement
ExplanationOfBenefit.insurance.focal ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.insurance.coverage ExplanationOfBenefit.item.bodySite.subSite
  • Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.accident.type ExplanationOfBenefit.item.reviewOutcome
  • Change binding strength from required to extensible Added Element
ExplanationOfBenefit.item.careTeamSequence ExplanationOfBenefit.item.reviewOutcome.decision
  • Renamed from careTeamLinkId to careTeamSequence Added Element
ExplanationOfBenefit.item.diagnosisSequence ExplanationOfBenefit.item.reviewOutcome.reason
  • Renamed from diagnosisLinkId to diagnosisSequence Added Element
ExplanationOfBenefit.item.procedureSequence ExplanationOfBenefit.item.reviewOutcome.preAuthRef
  • Renamed from procedureLinkId to procedureSequence Added Element
ExplanationOfBenefit.item.informationSequence ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod
  • Renamed from informationLinkId to informationSequence Added Element
ExplanationOfBenefit.item.productOrService ExplanationOfBenefit.item.adjudication.quantity
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.item.detail.productOrService ExplanationOfBenefit.item.adjudication.decisionDate
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService ExplanationOfBenefit.item.detail.traceNumber
  • Renamed from service to productOrService Added Element
ExplanationOfBenefit.item.detail.productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.itemSequence ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Renamed from sequenceLinkId to itemSequence Added Element
ExplanationOfBenefit.addItem.detailSequence ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.subDetailSequence ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.addItem.provider ExplanationOfBenefit.item.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.productOrService ExplanationOfBenefit.item.detail.subDetail.traceNumber
  • Renamed from service to productOrService Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.programCode ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.serviced[x] ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.location[x] ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.addItem.quantity ExplanationOfBenefit.item.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.unitPrice ExplanationOfBenefit.addItem.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.factor ExplanationOfBenefit.addItem.subject
  • Added Element
ExplanationOfBenefit.addItem.net ExplanationOfBenefit.addItem.informationSequence
  • Renamed from fee to net Added Element
ExplanationOfBenefit.addItem.bodySite ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.subSite ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.detail.productOrService ExplanationOfBenefit.addItem.productOrService
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.detail.quantity ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.unitPrice ExplanationOfBenefit.addItem.request
  • Added Element
ExplanationOfBenefit.addItem.detail.factor ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.productOrService ExplanationOfBenefit.addItem.bodySite
  • Added Mandatory Element Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.detail.subDetail.modifier ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.detail.subDetail.quantity ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice ExplanationOfBenefit.addItem.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.factor ExplanationOfBenefit.addItem.detail.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.net ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber ExplanationOfBenefit.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.subDetail.adjudication ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.adjudication ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.total ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.total.category ExplanationOfBenefit.addItem.detail.reviewOutcome
  • Added Mandatory Element
ExplanationOfBenefit.total.amount ExplanationOfBenefit.addItem.detail.subDetail.traceNumber
  • Added Mandatory Element
ExplanationOfBenefit.formCode ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.form ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Type Min Cardinality changed from CodeableConcept 1 to Attachment 0
ExplanationOfBenefit.processNote.type ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Type changed from CodeableConcept to code Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1 Added Element
ExplanationOfBenefit.processNote.language ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Change binding strength from extensible to preferred Added Element
ExplanationOfBenefit.benefitPeriod ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.organization ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome
  • deleted Added Element
ExplanationOfBenefit.payee.resourceType ExplanationOfBenefit.processNote.class
  • deleted Added Element
ExplanationOfBenefit.employmentImpacted ExplanationOfBenefit.processNote.type
  • deleted Type changed from code to CodeableConcept
    • ExplanationOfBenefit.hospitalization
  • deleted Change binding strength from required to extensible
ExplanationOfBenefit.item.detail.type ExplanationOfBenefit.processNote.text
  • deleted Type changed from string to markdown
ExplanationOfBenefit.item.detail.subDetail.type ExplanationOfBenefit.processNote.language
ExplanationOfBenefit.addItem.category ExplanationOfBenefit.patient
  • deleted Deleted
ExplanationOfBenefit.addItem.detail.revenue ExplanationOfBenefit.careTeam.responsible
  • deleted Deleted
ExplanationOfBenefit.addItem.detail.category ExplanationOfBenefit.careTeam.qualification
  • deleted Deleted
ExplanationOfBenefit.totalCost ExplanationOfBenefit.diagnosis.packageCode
  • deleted Deleted
ExplanationOfBenefit.unallocDeductable ExplanationOfBenefit.item.subSite
  • deleted Deleted
ExplanationOfBenefit.totalBenefit ExplanationOfBenefit.item.adjudication.value
  • deleted Deleted
ExplanationOfBenefit.benefitBalance.subCategory ExplanationOfBenefit.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). ) for R4B as XML or JSON .

Structure

1..1 1..1 BackboneElement 0..1 0..* value[x] 0..1 Data to be provided valueBoolean boolean valueString string 1..* BackboneElement 1..1 CodeableConcept Anatomical sub-location BackboneElement 1..1 see 1..1 CodeableConcept Anatomical sub-location see 1..1 see see display | print | printoper
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . ExplanationOfBenefit TU DomainResource Explanation of Benefit resource

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

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus Binding: Explanation Of Benefit Status ( Required )
. . . statusReason Σ 0..1 string Reason for status change
. . . type Σ 1..1 CodeableConcept Category or discipline
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient subject Σ 1..1 Reference ( Patient | Group ) The recipient recipient(s) of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Response creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Party responsible for reimbursement
. . . provider Σ 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority 0..1 CodeableConcept Desired processing urgency
ProcessPriority Binding: Process Priority Codes ( Example Preferred )
. . . fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
FundsReserve Binding: Funds Reservation Codes ( Example Preferred )
. . . fundsReserve 0..1 CodeableConcept Funds reserved status
FundsReserve Binding: Funds Reservation Codes ( Example Preferred )
. . . related 0..* BackboneElement Prior or corollary claims

. . . . claim 0..1 Reference ( Claim | ExplanationOfBenefit ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Binding: Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription ) Prescription authorizing services or products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription ) Original prescription if superceded by fulfiller
. . . payee event 0..* BackboneElement Event information

0..1
. . . . type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 0..1 CodeableConcept Category of recipient
PayeeType Binding: Claim Payee Type Codes ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment Referral
. . facility . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

. . . facility 0..1 Reference ( Location | Organization ) Servicing Facility
. . . claim 0..1 Reference ( Claim ) Claim reference
. . . claimResponse 0..1 Reference ( ClaimResponse ) Claim response reference
. . . outcome Σ 1..1 code queued | complete | error | partial
Binding: Claim Processing Codes ( Required )
. . disposition . decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Preferred )
... disposition 0..1 string Disposition Message
. . . preAuthRef 0..* string Preauthorization reference

. . . preAuthRefPeriod 0..* Period Preauthorization in-effect period

. . careTeam . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
. . . careTeam 0..* BackboneElement Care Team members

. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization responsible 0..1 boolean
Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Binding: Claim Care Team Role Codes ( Example Preferred )
. . . qualification . specialty 0..1 CodeableConcept Practitioner credential or provider specialization
Binding: Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information

. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept Classification of the supplied information
Binding: Claim Information Category Codes ( Example Preferred )
. . . . code 0..1 CodeableConcept Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . timingDate . timingDateTime date dateTime
. . . . . timingPeriod Period
. . . . . valueQuantity timingTiming Quantity Timing
. . . . valueAttachment Attachment value[x] valueReference 0..1 Reference ( Any * ) Data to be provided
. . . . reason 0..1 Coding Explanation for the information
Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information

. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes ( Example Preferred )

. . . . onAdmission 0..1 CodeableConcept Present on admission
Binding: Example Diagnosis on Admission Codes ( Example Preferred ) packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
. . . procedure 0..* BackboneElement Clinical procedures performed

. . . . sequence 1..1 positiveInt Procedure instance identifier
. . . . type 0..* CodeableConcept Category of Procedure
Binding: Example Procedure Type Codes ( Example Preferred )

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
. . . insurance Σ 0..* BackboneElement Patient insurance information

. . . . focal Σ 1..1 boolean Coverage to be used for adjudication
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . preAuthRef 0..* string Prior authorization reference number

. . . accident 0..1 BackboneElement Details of the event
. . . . date 0..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . item . patientPaid 0..1 Money Paid by the patient
0..*
. . . item 0..* BackboneElement Product or service provided

. . . . sequence 1..1 positiveInt Item instance identifier
. . . . careTeamSequence 0..* positiveInt Applicable care team members

. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses

. . . . procedureSequence 0..* positiveInt Applicable procedures

. . . . informationSequence 0..* positiveInt Applicable exception and supporting information

. . . revenue . traceNumber 0..* Identifier Number for tracking

. . . . subject 0..1 Reference ( Patient | Group ) The recipient of the products and services
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . modifier . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . patientPaid 0..1 Money Paid by the patient
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total tax
0..1
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . bodySite 0..* BackboneElement Anatomical location

0..1
. . . . . site Anatomical location 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item associated with the listed treatments

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 0..1 BackboneElement Adjudication results
. . . . . decision 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Preferred )
..... reason 0..* CodeableConcept BackboneElement Reason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes ( Example )

. . . . . preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* BackboneElement Adjudication details

. . . . . category 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example Preferred )
. . . . . reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . value . quantity 0..1 decimal Quantity Non-monitary value
. . . . detail . decisionDate 0..1 dateTime When was adjudication performed
0..*
. . . . detail 0..* BackboneElement Additional items

. . . . . sequence 1..1 positiveInt Product or service provided
. . . . . revenue traceNumber 0..* Identifier Number for tracking

0..1
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . . quantity patientPaid 0..1 Money Paid by the patient
0..1
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . net . tax 0..1 Money Total tax
0..1
. . . . . net 0..1 Money Total item cost
. . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 0..1 see reviewOutcome Detail level adjudication results
0..*
. . . . . adjudication 0..* see adjudication Detail level adjudication details

. . . . . subDetail 0..* BackboneElement Additional items

. . . . . . sequence 1..1 positiveInt Product or service provided
. . . . . revenue . traceNumber 0..* Identifier Number for tracking

0..1
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
0..*
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . . quantity . patientPaid 0..1 Money Paid by the patient
0..1
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total tax
0..1
. . . . . . net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details

. . . addItem 0..* BackboneElement Insurer added line items

. . . . itemSequence 0..* positiveInt Item sequence number

. . . . detailSequence 0..* positiveInt Detail sequence number

. . . . subDetailSequence 0..* positiveInt Subdetail sequence number

. . . provider . traceNumber 0..* Identifier Number for tracking

. . . . subject 0..1 Reference ( Patient | Group ) The recipient of the products and services
.... informationSequence 0..* positiveInt Applicable exception and supporting information

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

. . . productOrService . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
1..1
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . modifier . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

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

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . patientPaid 0..1 Money Paid by the patient
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total item cost tax
. . . . bodySite net 0..1 Money Total item cost
0..1
. . . . bodySite 0..* BackboneElement Anatomical location

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

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem level adjudication results
0..*
. . . . adjudication 0..* see adjudication Added items adjudication

. . . . detail 0..* BackboneElement Insurer added line items

. . . . productOrService . traceNumber 0..* Identifier Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . quantity patientPaid 0..1 Money Paid by the patient
0..1
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . net . tax 0..1 Money Total tax
0..1
. . . . . net 0..1 Money Total item cost
. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem detail level adjudication results
0..*
. . . . . adjudication 0..* see adjudication Added items adjudication

. . . . . subDetail 0..* BackboneElement Insurer added line items

. . . . . productOrService . traceNumber 0..* Identifier Number for tracking

1..1
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . quantity patientPaid 0..1 Money Paid by the patient
0..1
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . net . tax 0..1 Money Total tax
0..1
. . . . . . net 0..1 Money Total item cost
. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . adjudication reviewOutcome 0..1 see reviewOutcome Additem subdetail level adjudication results
0..*
. . . . . . adjudication 0..* see adjudication Added items adjudication

. . . adjudication 0..* see adjudication Header-level adjudication

. . . total Σ 0..* BackboneElement Adjudication totals

. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Financial total for the category
. . . payment 0..1 BackboneElement Payment Details
. . . . type 0..1 CodeableConcept Partial or complete payment
Binding: Example Payment Type Codes ( Example Preferred )
. . . . adjustment 0..1 Money Payment adjustment for non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: Payment Adjustment Reason Codes ( Example Preferred )
. . . . date 0..1 date Expected date of payment
. . . . amount 0..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment
. . . formCode 0..1 CodeableConcept Printed form identifier
Forms Binding: Form Codes ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Note concerning adjudication

. . . number . class 0..1 CodeableConcept Business kind of note
Binding: ProcessNoteClass ( Example )
0..1
. . . . number 0..1 positiveInt Note instance identifier
. . . . type 0..1 code CodeableConcept Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 0..1 string markdown Note explanatory text
. . . . language 0..1 CodeableConcept Language of the text
Common Binding: All Languages ( Preferred but limited to AllLanguages Required )
Additional Bindings Purpose
Common Languages Starter

. . . benefitPeriod 0..1 Period When the benefits are applicable
. . . benefitBalance 0..* BackboneElement Balance by Benefit Category

. . . . category 1..1 CodeableConcept Benefit classification
Binding: Benefit Category 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
Binding: Network Type Codes ( Example )
. . . . unit 0..1 CodeableConcept Individual or family
Binding: Unit Type Codes ( Example )
. . . . term 0..1 CodeableConcept Annual or lifetime
Binding: Benefit Term Codes ( Example )
. . . . financial 0..* BackboneElement Benefit Summary

. . . . . type 1..1 CodeableConcept Benefit classification
Binding: 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

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

ExplanationOfBenefit ( DomainResource ) A unique identifier assigned to this explanation of benefit identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) ExplanationOfBenefitStatus ! » Used to indicate why the status has changed statusReason : string [0..1] The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services which could are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « Complete, proposed, exploratory, other. null (Strength=Required) Use ! » The party party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought patient subject : Reference [1..1] « Patient | Group » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The party responsible for authorization, adjudication and reimbursement insurer : Reference [1..1] [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization provider : Reference [1..1] [0..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine normal deferred priority : CodeableConcept [0..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example) null (Strength=Preferred) ProcessPriority ProcessPriorityCodes ?? ? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserveRequested : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) null (Strength=Preferred) Funds Reservation ?? FundsReservationCodes ? » A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) null (Strength=Preferred) Funds Reservation FundsReservationCodes ?? ? » Prescription is the document/authorization given to support the dispensing of pharmacy, device or vision claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments prescription : Reference [0..1] « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » A reference The referral information received by the claim author, it is not to be used when the author generates a referral resource for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] « ServiceRequest » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » Facility where the services were provided facility : Reference [0..1] « Location | Organization » The business identifier for the instance of the adjudication request: claim predetermination or preauthorization claim : Reference [0..1] « Claim » The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response claimResponse : Reference [0..1] « ClaimResponse » The outcome of the claim, predetermination, or preauthorization processing outcome : code [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing. (Strength=Required) claim, predetermination, or preauthorization adjudication ClaimProcessingCodes ! decision : CodeableConcept [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..*] The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided preAuthRefPeriod : Period [0..*] A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » This indicates the relative order of a series of EOBs related to different coverages for the same suite of services precedence : positiveInt [0..1] The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] A code for the form to be used for printing the content formCode : CodeableConcept [0..1] « The forms codes. null (Strength=Example) Form FormCodes ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] The term of the benefits documented in this response benefitPeriod : Period [0..1] RelatedClaim Reference to a related Claim or ExplanationOfBenefit as a representation of a claim claim : Reference [0..1] « Claim | ExplanationOfBenefit » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. null (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » Payee Type of Party to be reimbursed: Subscriber, billing provider, other type : CodeableConcept [0..1] « A code for the party to be reimbursed. null (Strength=Example) Claim Payee Type ClaimPayeeTypeCodes ?? » Reference to the individual or organization to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) null (Strength=Preferred) ClaimCareTeamRoleCodes ?? ? » The qualification specialization of the practitioner or provider which is applicable for this service qualification specialty : CodeableConcept [0..1] « Provider professional qualifications. null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example) null (Strength=Preferred) ClaimInformationCategoryCodes ?? ? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [0..1] « date dateTime | Period | Timing » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type * [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » Provides the reason in the situation where a reason code is required in addition to the content reason : Coding [0..1] « Reason codes for the missing teeth. null (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. null (Strength=Example) ICD-10Codes ICD10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example) null (Strength=Preferred) ExampleDiagnosisTypeCodes ?? ? » Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » 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 packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) null (Strength=Preferred) ExampleDiagnosisRelatedGroupC... ExampleDiagnosisOnAdmissionCo... ?? ? » Procedure A number to uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example) null (Strength=Preferred) ExampleProcedureTypeCodes ?? ? » Date and optionally time the procedure was performed date : dateTime [0..1] The code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); ICD10 Procedure codes. null (Strength=Example) ICD-10ProcedureCodes ICD10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] Accident Date of an accident event related to the products and services contained in the claim date : date [0..1] The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. null (Strength=Extensible) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] Care team members related to this service or product careTeamSequence : positiveInt [0..*] Diagnoses applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought subject : Reference [0..1] « Patient | Group » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place where the service is rendered. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] ItemBodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » ReviewOutcome A billed item may include goods The result of the claim, predetermination, or services provided in multiple encounters preauthorization adjudication encounter decision : Reference CodeableConcept [0..*] [0..1] « Encounter null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » The numbers associated with notes below reasons for the result of the claim, predetermination, or preauthorization adjudication reason : CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which apply is used in later communications which refers to the this adjudication of preAuthRef : string [0..1] The time frame during which this item authorization is effective noteNumber preAuthPeriod : positiveInt Period [0..*] [0..1] Adjudication 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 category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) null (Strength=Preferred) AdjudicationValueCodes ?? ? » A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « Adjudication reason codes. null (Strength=Example) AdjudicationReasonCodes ?? » Monetary amount associated with the category amount : Money [0..1] A non-monetary value associated with the category. Mutually exclusive to the amount element above value quantity : decimal Quantity [0..1] The date and time the adjudication decision occured decisionDate : dateTime [0..1] Detail A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the details within the claim item which this line is intended to replace detailSequence : positiveInt [0..*] The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace subDetailSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought subject : Reference [0..1] « Patient | Group » Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The providers who are authorized for the services rendered to the patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place where the service is rendered. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemBodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » AddedItemDetail The numbers associated with notes below which apply to Trace number for tracking purposes. May be defined at the adjudication of this item jurisdiction level or between trading partners noteNumber traceNumber : positiveInt Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « AddedItemDetail null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemDetailSubDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Total 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » Monetary total amount associated with the category amount : Money [1..1] Payment Whether this represents partial or complete payment of the benefits payable type : CodeableConcept [0..1] « The type (partial, complete) of the payment. (Strength=Example) null (Strength=Preferred) ExamplePaymentTypeCodes ?? ? » Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) null (Strength=Preferred) PaymentAdjustmentReasonCodes ?? ? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Benefits payable less any payment adjustment amount : Money [0..1] Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note A code to indicate the business purpose of the note class : CodeableConcept [0..1] « null (Strength=Example) ProcessNoteClass?? » A number to uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note text type : code CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The explanation or description associated with the processing text : string markdown [0..1] A code to define the language used in the text of the note language : CodeableConcept [0..1] « A human language. (Strength=Preferred) null (Strength=Required) CommonLanguages ? AllLanguages ! » BenefitBalance Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision, oral-basic etc. null (Strength=Example) BenefitCategoryCodes ?? » True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit name : string [0..1] A richer description of the benefit or services covered description : string [0..1] Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers network : CodeableConcept [0..1] « Code to classify in or out of network services. null (Strength=Example) NetworkTypeCodes ?? » Indicates if the benefits apply to an individual or to the family unit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. null (Strength=Example) UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. null (Strength=Example) BenefitTermCodes ?? » Benefit Classification of benefit being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. null (Strength=Example) BenefitTypeCodes ?? » The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » The quantity of the benefit which have been consumed to date used[x] : Type DataType [0..1] « unsignedInt | Money » Other claims which are related to this claim such as prior submissions or claims for related services or for the same event related [0..*] Information code for an event with a corresponding date or period event [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] The members of the team who provided the products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] [0..*] Details of a accident which resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] 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 adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] Third-tier of goods and services subDetail [0..*] Second-tier of goods and services detail [0..*] A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details item [0..*] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The third-tier service adjudications for payor payer added services subDetail [0..*] The second-tier service adjudications for payor payer added services detail [0..*] The first-tier service adjudications for payor payer added product or service lines addItem [0..*] The adjudication results which are presented at the header level rather than at the line-item or add-item levels adjudication [0..*] Categorized monetary totals for the adjudication total [0..*] Payment details for the adjudication of the claim payment [0..1] A note that describes or explains adjudication results in a human readable form processNote [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template 

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for the resource --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <statusReason value="[string]"/><!-- 0..1 Reason for status change -->

 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <
 <</patient>

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <subject><!-- 1..1 Reference(Group|Patient) The recipient(s) of the products and services --></subject>

 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <</enterer>
 <</insurer>
 <</provider>
 <</priority>

 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>

 <fundsReserveRequested><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserveRequested>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <</claim>

  <claim><!-- 0..1 Reference(Claim|ExplanationOfBenefit) Reference to the related claim --></claim>

  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <</prescription>
 <</originalPrescription>

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|ServiceRequest|
   VisionPrescription) Prescription authorizing services or products --></prescription>

 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   ServiceRequest|VisionPrescription) Original prescription if superceded by fulfiller --></originalPrescription>

 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <</type>
  <|

  <type><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>

 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <

 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..* Preauthorization reference -->
 <preAuthRefPeriod><!-- 0..* Period Preauthorization in-effect period --></preAuthRefPeriod>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>

 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <</provider>
  <

  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>

  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <</qualification>

  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <</timing[x]>
  <</value[x]>

  <timing[x]><!-- 0..1 dateTime|Period|Timing When it occurred --></timing[x]>
  <value[x]><!-- 0..1 * Data to be provided --></value[x]>

  <reason><!-- 0..1 Coding Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <</packageCode>

 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <

 <insurance>  <!-- 0..* Patient insurance information -->

  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable care team members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <subject><!-- 0..1 Reference(Group|Patient) The recipient of the products and services --></subject>

  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <</productOrService>

  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>

  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <</bodySite>
  <</subSite>
  <</encounter>

  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>

  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <quantity><!-- 0..1 Quantity Non-monitary value --></quantity>
   <decisionDate value="[dateTime]"/><!-- 0..1 When was adjudication performed -->

  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <</productOrService>

   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Detail level adjudication results --></reviewOutcome>

   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Product or service provided -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <</productOrService>

    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <

 <addItem>  <!-- 0..* Insurer added line items -->

  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <</provider>
  <</productOrService>

  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <subject><!-- 0..1 Reference(Group|Patient) The recipient of the products and services --></subject>
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</bodySite>
  <</subSite>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem level adjudication results --></reviewOutcome>

  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <
   <</productOrService>

  <detail>  <!-- 0..* Insurer added line items -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem detail level adjudication results --></reviewOutcome>

   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <
    <</productOrService>

   <subDetail>  <!-- 0..* Insurer added line items -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ExplanationOfBenefit.item.reviewOutcome Additem subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 0..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the variance --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <class><!-- 0..1 CodeableConcept Business kind of note --></class>

  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <
  <
  <</language>

  <type><!-- 0..1 CodeableConcept Note purpose --></type>
  <text value="[markdown]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit classification --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Benefit classification --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template 

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for the resource
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "statusReason" : "<string>", // Reason for status change

  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "subject" : { Reference(Group|Patient) }, // R!  The recipient(s) of the products and services

  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Response creation date
  "
  "
  "
  "

  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency

  "fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "related" : [{ // Prior or corollary claims
    "

    "claim" : { Reference(Claim|ExplanationOfBenefit) }, // Reference to the related claim

    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "
  "

  "prescription" : { Reference(DeviceRequest|MedicationRequest|ServiceRequest|
   VisionPrescription) }, // Prescription authorizing services or products

  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   ServiceRequest|VisionPrescription) }, // Original prescription if superceded by fulfiller

  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "payee" : { // Recipient of benefits payable
    "
    "|

    "type" : { CodeableConcept }, // Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) } // Recipient reference
  },
  "
  "

  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing Facility

  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "

  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication

  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : ["<string>"], // Preauthorization reference
  "preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code

  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Order of care team
    "
    "

    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization

    "role" : { CodeableConcept }, // Function within the team
    "

    "specialty" : { CodeableConcept } // Practitioner or provider specialization

  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    
    ">",

    // timing[x]: When it occurred. One of these 3:
    "timingDateTime" : "<dateTime>",

    "timingPeriod" : { Period },
    

    "timingTiming" : { Timing },
    // value[x]: Data to be provided. One of these 55:

    "valueBase64Binary" : "<base64Binary>",

    "valueBoolean" : <boolean>,
    "valueCanonical" : "<canonical>",
    "valueCode" : "<code>",
    "valueDate" : "<date>",
    "valueDateTime" : "<dateTime>",
    "valueDecimal" : <decimal>,
    "valueId" : "<id>",
    "valueInstant" : "<instant>",
    "valueInteger" : <integer>,
    "valueInteger64" : "<integer64>",
    "valueMarkdown" : "<markdown>",
    "valueOid" : "<oid>",
    "valuePositiveInt" : "<positiveInt>",

    "valueString" : "<string>",
    " },

    "valueTime" : "<time>",
    "valueUnsignedInt" : "<unsignedInt>",
    "valueUri" : "<uri>",
    "valueUrl" : "<url>",
    "valueUuid" : "<uuid>",
    "valueAddress" : { Address },
    "valueAge" : { Age },
    "valueAnnotation" : { Annotation },

    "valueAttachment" : { Attachment },
    " },

    "valueCodeableConcept" : { CodeableConcept },
    "valueCodeableReference" : { CodeableReference },
    "valueCoding" : { Coding },
    "valueContactPoint" : { ContactPoint },
    "valueCount" : { Count },
    "valueDistance" : { Distance },
    "valueDuration" : { Duration },
    "valueHumanName" : { HumanName },
    "valueIdentifier" : { Identifier },
    "valueMoney" : { Money },
    "valuePeriod" : { Period },
    "valueQuantity" : { Quantity },
    "valueRange" : { Range },
    "valueRatio" : { Ratio },
    "valueRatioRange" : { RatioRange },
    "valueReference" : { Reference },
    "valueSampledData" : { SampledData },
    "valueSignature" : { Signature },
    "valueTiming" : { Timing },
    "valueContactDetail" : { ContactDetail },
    "valueDataRequirement" : { DataRequirement },
    "valueExpression" : { Expression },
    "valueParameterDefinition" : { ParameterDefinition },
    "valueRelatedArtifact" : { RelatedArtifact },
    "valueTriggerDefinition" : { TriggerDefinition },
    "valueUsageContext" : { UsageContext },
    "valueAvailability" : { Availability },
    "valueExtendedContactDetail" : { ExtendedContactDetail },
    "valueVirtualServiceDetail" : { VirtualServiceDetail },
    "valueDosage" : { Dosage },
    "valueMeta" : { Meta },

    "reason" : { Coding } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "
    "

    "onAdmission" : { CodeableConcept } // Present on admission

  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "

  "insurance" : [{ // Patient insurance information

    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "preAuthRef" : ["<string>"] // Prior authorization reference number
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // When the incident occurred
    "

    "type" : { CodeableConcept }, // The nature of the accident icon

    // location[x]: Where the event occurred. One of these 2:
    " }

    "locationAddress" : { Address },

    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable care team members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "traceNumber" : [{ Identifier }], // Number for tracking
    "subject" : { Reference(Group|Patient) }, // The recipient of the products and services

    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "

    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost

    "udi" : [{ Reference(Device) }], // Unique device identifier
    "
    "
    "

    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },

    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "

      "quantity" : { Quantity }, // Non-monitary value
      "decisionDate" : "<dateTime>" // When was adjudication performed

    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Product or service provided
      "traceNumber" : [{ Identifier }], // Number for tracking

      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "

      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "udi" : [{ Reference(Device) }], // Unique device identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Detail level adjudication results

      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Product or service provided
        "traceNumber" : [{ Identifier }], // Number for tracking

        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "

        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "udi" : [{ Reference(Device) }], // Unique device identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Subdetail level adjudication results

        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "

  "addItem" : [{ // Insurer added line items

    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "
    "

    "traceNumber" : [{ Identifier }], // Number for tracking
    "subject" : { Reference(Group|Patient) }, // The recipient of the products and services
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "
    "
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem level adjudication results

    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "
      "

    "detail" : [{ // Insurer added line items
      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem detail level adjudication results

      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "
        "

      "subDetail" : [{ // Insurer added line items
        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ExplanationOfBenefit.item.reviewOutcome }, // Additem subdetail level adjudication results

        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the variance
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "class" : { CodeableConcept }, // Business kind of note

    "number" : "<positiveInt>", // Note instance identifier
    "
    "
    "

    "type" : { CodeableConcept }, // Note purpose
    "text" : "<markdown>", // Note explanatory text
    "language" : { CodeableConcept } // Language of the text

  }],
  "benefitPeriod" : { Period }, // When the benefits are applicable
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit classification
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Benefit classification
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      ">"

      "usedUnsignedInt" : "<unsignedInt>",

      "usedMoney" : { Money }
    }]
  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
    ], ...;
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      # . One of these 3
        fhir: ]
        fhir: ]
        fhir: ]
      # . One of these 2
        fhir: ]
        fhir: ]
    ], ...;
  ], ...;

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for the resource
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:statusReason [ string ] ; # 0..1 Reason for status change
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 The recipient(s) of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Response creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserveRequested [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim|ExplanationOfBenefit) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|ServiceRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services or products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|ServiceRequest|VisionPrescription) ] ; # 0..1 Original prescription if superceded by fulfiller
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:DateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 0..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment Referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing Facility
  fhir:claim [ Reference(Claim) ] ; # 0..1 Claim reference
  fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Claim response reference
  fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial
  fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
  fhir:disposition [ string ] ; # 0..1 Disposition Message
  fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Preauthorization reference
  fhir:preAuthRefPeriod  ( [ Period ] ... ) ; # 0..* Preauthorization in-effect period
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:careTeam ( [ # 0..* Care Team members
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 3
      fhir:timing [  a fhir:DateTime ; dateTime ]
      fhir:timing [  a fhir:Period ; Period ]
      fhir:timing [  a fhir:Timing ; Timing ]
    # value[x] : 0..1 Data to be provided. One of these 55
      fhir:value [  a fhir:Base64Binary ; base64Binary ]
      fhir:value [  a fhir:Boolean ; boolean ]
      fhir:value [  a fhir:Canonical ; canonical ]
      fhir:value [  a fhir:Code ; code ]
      fhir:value [  a fhir:Date ; date ]
      fhir:value [  a fhir:DateTime ; dateTime ]
      fhir:value [  a fhir:Decimal ; decimal ]
      fhir:value [  a fhir:Id ; id ]
      fhir:value [  a fhir:Instant ; instant ]
      fhir:value [  a fhir:Integer ; integer ]
      fhir:value [  a fhir:Integer64 ; integer64 ]
      fhir:value [  a fhir:Markdown ; markdown ]
      fhir:value [  a fhir:Oid ; oid ]
      fhir:value [  a fhir:PositiveInt ; positiveInt ]
      fhir:value [  a fhir:String ; string ]
      fhir:value [  a fhir:Time ; time ]
      fhir:value [  a fhir:UnsignedInt ; unsignedInt ]
      fhir:value [  a fhir:Uri ; uri ]
      fhir:value [  a fhir:Url ; url ]
      fhir:value [  a fhir:Uuid ; uuid ]
      fhir:value [  a fhir:Address ; Address ]
      fhir:value [  a fhir:Age ; Age ]
      fhir:value [  a fhir:Annotation ; Annotation ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:value [  a fhir:CodeableReference ; CodeableReference ]
      fhir:value [  a fhir:Coding ; Coding ]
      fhir:value [  a fhir:ContactPoint ; ContactPoint ]
      fhir:value [  a fhir:Count ; Count ]
      fhir:value [  a fhir:Distance ; Distance ]
      fhir:value [  a fhir:Duration ; Duration ]
      fhir:value [  a fhir:HumanName ; HumanName ]
      fhir:value [  a fhir:Identifier ; Identifier ]
      fhir:value [  a fhir:Money ; Money ]
      fhir:value [  a fhir:Period ; Period ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Range ; Range ]
      fhir:value [  a fhir:Ratio ; Ratio ]
      fhir:value [  a fhir:RatioRange ; RatioRange ]
      fhir:value [  a fhir:Reference ; Reference ]
      fhir:value [  a fhir:SampledData ; SampledData ]
      fhir:value [  a fhir:Signature ; Signature ]
      fhir:value [  a fhir:Timing ; Timing ]
      fhir:value [  a fhir:ContactDetail ; ContactDetail ]
      fhir:value [  a fhir:DataRequirement ; DataRequirement ]
      fhir:value [  a fhir:Expression ; Expression ]
      fhir:value [  a fhir:ParameterDefinition ; ParameterDefinition ]
      fhir:value [  a fhir:RelatedArtifact ; RelatedArtifact ]
      fhir:value [  a fhir:TriggerDefinition ; TriggerDefinition ]
      fhir:value [  a fhir:UsageContext ; UsageContext ]
      fhir:value [  a fhir:Availability ; Availability ]
      fhir:value [  a fhir:ExtendedContactDetail ; ExtendedContactDetail ]
      fhir:value [  a fhir:VirtualServiceDetail ; VirtualServiceDetail ]
      fhir:value [  a fhir:Dosage ; Dosage ]
      fhir:value [  a fhir:Meta ; Meta ]
    fhir:reason [ Coding ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:precedence [ positiveInt ] ; # 0..1 Precedence (primary, secondary, etc.)
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 0..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable care team members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:subject [ Reference(Group|Patient) ] ; # 0..1 The recipient of the products and services
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:Date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ # 0..1 Adjudication results
      fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
      fhir:reason  ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication
      fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
      fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
    ] ;
    fhir:adjudication ( [ # 0..* Adjudication details
      fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
      fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome
      fhir:amount [ Money ] ; # 0..1 Monetary amount
      fhir:quantity [ Quantity ] ; # 0..1 Non-monitary value
      fhir:decisionDate [ dateTime ] ; # 0..1 When was adjudication performed
    ] ... ) ;
    fhir:detail ( [ # 0..* Additional items
      fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Detail level adjudication results
      fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Detail level adjudication details
      fhir:subDetail ( [ # 0..* Additional items
        fhir:sequence [ positiveInt ] ; # 1..1 Product or service provided
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results
        fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:addItem ( [ # 0..* Insurer added line items
    fhir:itemSequence  ( [ positiveInt ] ... ) ; # 0..* Item sequence number
    fhir:detailSequence  ( [ positiveInt ] ... ) ; # 0..* Detail sequence number
    fhir:subDetailSequence  ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:subject [ Reference(Group|Patient) ] ; # 0..1 The recipient of the products and services
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:provider  ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:Date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem level adjudication results
    fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
    fhir:detail ( [ # 0..* Insurer added line items
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem detail level adjudication results
      fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
      fhir:subDetail ( [ # 0..* Insurer added line items
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ExplanationOfBenefit.item.reviewOutcome ] ; # 0..1 Additem subdetail level adjudication results
        fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Added items adjudication
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:adjudication  ( [ See ExplanationOfBenefit.item.adjudication ] ... ) ; # 0..* Header-level adjudication
  fhir:total ( [ # 0..* Adjudication totals
    fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
    fhir:amount [ Money ] ; # 1..1 Financial total for the category
  ] ... ) ;
  fhir:payment [ # 0..1 Payment Details
    fhir:type [ CodeableConcept ] ; # 0..1 Partial or complete payment
    fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues
    fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the variance
    fhir:date [ date ] ; # 0..1 Expected date of payment
    fhir:amount [ Money ] ; # 0..1 Payable amount after adjustment
    fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment
  ] ;
  fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier
  fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form
  fhir:processNote ( [ # 0..* Note concerning adjudication
    fhir:class [ CodeableConcept ] ; # 0..1 Business kind of note
    fhir:number [ positiveInt ] ; # 0..1 Note instance identifier
    fhir:type [ CodeableConcept ] ; # 0..1 Note purpose
    fhir:text [ markdown ] ; # 0..1 Note explanatory text
    fhir:language [ CodeableConcept ] ; # 0..1 Language of the text
  ] ... ) ;
  fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable
  fhir:benefitBalance ( [ # 0..* Balance by Benefit Category
    fhir:category [ CodeableConcept ] ; # 1..1 Benefit classification
    fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan
    fhir:name [ string ] ; # 0..1 Short name for the benefit
    fhir:description [ string ] ; # 0..1 Description of the benefit or services covered
    fhir:network [ CodeableConcept ] ; # 0..1 In or out of network
    fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family
    fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime
    fhir:financial ( [ # 0..* Benefit Summary
      fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification
      # allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:allowed [  a fhir:UnsignedInt ; unsignedInt ]
        fhir:allowed [  a fhir:String ; string ]
        fhir:allowed [  a fhir:Money ; Money ]
      # used[x] : 0..1 Benefits used. One of these 2
        fhir:used [  a fhir:UnsignedInt ; unsignedInt ]
        fhir:used [  a fhir:Money ; Money ]
    ] ... ) ;
  ] ... ) ;

]

Changes since Release 3 from both R4 and R4B

ExplanationOfBenefit.addItem.detail.net Renamed from fee to net
ExplanationOfBenefit
ExplanationOfBenefit.status ExplanationOfBenefit.traceNumber
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/explanationofbenefit-status to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 Added Element
ExplanationOfBenefit.type ExplanationOfBenefit.statusReason
  • Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Added Element
ExplanationOfBenefit.subType ExplanationOfBenefit.subject
  • Max Cardinality changed from * to 1 Added Mandatory Element
ExplanationOfBenefit.use ExplanationOfBenefit.enterer
  • Type Reference: Added Mandatory Element Target Types Patient, RelatedPerson
ExplanationOfBenefit.patient ExplanationOfBenefit.insurer
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.created ExplanationOfBenefit.provider
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.enterer ExplanationOfBenefit.related.claim
  • Type Reference: Added Target Type PractitionerRole ExplanationOfBenefit
ExplanationOfBenefit.insurer ExplanationOfBenefit.prescription
  • Min Cardinality changed from 0 to 1 Type Reference: Added Target Types DeviceRequest, ServiceRequest
ExplanationOfBenefit.provider ExplanationOfBenefit.originalPrescription
    Min Cardinality changed from 0 to 1
  • Type Reference: Added Target Types PractitionerRole, Organization DeviceRequest, ServiceRequest, VisionPrescription
ExplanationOfBenefit.priority ExplanationOfBenefit.event
  • Added Element
ExplanationOfBenefit.fundsReserveRequested ExplanationOfBenefit.event.type
  • Added Mandatory Element
ExplanationOfBenefit.fundsReserve ExplanationOfBenefit.event.when[x]
  • Added Mandatory Element
ExplanationOfBenefit.payee.party ExplanationOfBenefit.encounter
  • Type Reference: Added Target Type PractitionerRole Element
ExplanationOfBenefit.referral ExplanationOfBenefit.facility
  • Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Organization
ExplanationOfBenefit.outcome
  • Min Cardinality changed from 0 to 1 Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to code Claim Processing Codes
ExplanationOfBenefit.decision
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required) Added Element
ExplanationOfBenefit.preAuthRef ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.preAuthRefPeriod ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.careTeam.provider ExplanationOfBenefit.supportingInfo.timing[x]
  • Add Types dateTime, Timing
  • Remove Type Reference: Added Target Type PractitionerRole date
ExplanationOfBenefit.supportingInfo ExplanationOfBenefit.supportingInfo.value[x]
  • Renamed from information to supportingInfo Add Types base64Binary, canonical, code, date, dateTime, decimal, id, instant, integer, integer64, markdown, oid, positiveInt, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, CodeableConcept, CodeableReference, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Range, Ratio, RatioRange, SampledData, Signature, Timing, ContactDetail, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Availability, ExtendedContactDetail, VirtualServiceDetail, Dosage, Meta
ExplanationOfBenefit.supportingInfo.sequence ExplanationOfBenefit.insurance
  • Moved Min Cardinality changed from ExplanationOfBenefit.information 1 to ExplanationOfBenefit.supportingInfo 0
ExplanationOfBenefit.supportingInfo.category ExplanationOfBenefit.patientPaid
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.code ExplanationOfBenefit.item.traceNumber
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.timing[x] ExplanationOfBenefit.item.subject
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.supportingInfo.value[x] ExplanationOfBenefit.item.productOrService
  • Moved Min Cardinality changed from ExplanationOfBenefit.information 1 to ExplanationOfBenefit.supportingInfo Add Type boolean 0
ExplanationOfBenefit.supportingInfo.reason ExplanationOfBenefit.item.productOrServiceEnd
  • Moved from ExplanationOfBenefit.information to ExplanationOfBenefit.supportingInfo Added Element
ExplanationOfBenefit.diagnosis.onAdmission ExplanationOfBenefit.item.request
  • Added Element
ExplanationOfBenefit.procedure.type ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.procedure.udi ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.insurance ExplanationOfBenefit.item.bodySite
  • Min Max Cardinality changed from 0 to 1 to *
  • Max Cardinality Type changed from 1 CodeableConcept to * BackboneElement
ExplanationOfBenefit.insurance.focal ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.insurance.coverage ExplanationOfBenefit.item.bodySite.subSite
  • Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.accident.type ExplanationOfBenefit.item.reviewOutcome
  • Change binding strength from required to extensible Added Element
ExplanationOfBenefit.item.careTeamSequence ExplanationOfBenefit.item.reviewOutcome.decision
  • Renamed from careTeamLinkId to careTeamSequence Added Element
ExplanationOfBenefit.item.diagnosisSequence ExplanationOfBenefit.item.reviewOutcome.reason
  • Renamed from diagnosisLinkId to diagnosisSequence Added Element
ExplanationOfBenefit.item.procedureSequence ExplanationOfBenefit.item.reviewOutcome.preAuthRef
  • Renamed from procedureLinkId to procedureSequence Added Element
ExplanationOfBenefit.item.informationSequence ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod
  • Renamed from informationLinkId to informationSequence Added Element
ExplanationOfBenefit.item.productOrService ExplanationOfBenefit.item.adjudication.quantity
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.item.detail.productOrService ExplanationOfBenefit.item.adjudication.decisionDate
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService ExplanationOfBenefit.item.detail.traceNumber
  • Renamed from service to productOrService Added Element
ExplanationOfBenefit.item.detail.productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.itemSequence ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Renamed from sequenceLinkId to itemSequence Added Element
ExplanationOfBenefit.addItem.detailSequence ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.subDetailSequence ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.addItem.provider ExplanationOfBenefit.item.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.productOrService ExplanationOfBenefit.item.detail.subDetail.traceNumber
  • Renamed from service to productOrService Added Element
ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.programCode ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.serviced[x] ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.location[x] ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.addItem.quantity ExplanationOfBenefit.item.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.unitPrice ExplanationOfBenefit.addItem.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.factor ExplanationOfBenefit.addItem.subject
  • Added Element
ExplanationOfBenefit.addItem.net ExplanationOfBenefit.addItem.informationSequence
  • Renamed from fee to net Added Element
ExplanationOfBenefit.addItem.bodySite ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.subSite ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.detail.productOrService ExplanationOfBenefit.addItem.productOrService
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
ExplanationOfBenefit.addItem.detail.quantity ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.detail.unitPrice ExplanationOfBenefit.addItem.request
  • Added Element
ExplanationOfBenefit.addItem.detail.factor ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.productOrService ExplanationOfBenefit.addItem.bodySite
  • Added Mandatory Element Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.detail.subDetail.modifier ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.detail.subDetail.quantity ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice ExplanationOfBenefit.addItem.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.factor ExplanationOfBenefit.addItem.detail.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.net ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber ExplanationOfBenefit.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.detail.subDetail.adjudication ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.adjudication ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.total ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.total.category ExplanationOfBenefit.addItem.detail.reviewOutcome
  • Added Mandatory Element
ExplanationOfBenefit.total.amount ExplanationOfBenefit.addItem.detail.subDetail.traceNumber
  • Added Mandatory Element
ExplanationOfBenefit.formCode ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.form ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Type Min Cardinality changed from CodeableConcept 1 to Attachment 0
ExplanationOfBenefit.processNote.type ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Type changed from CodeableConcept to code Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1 Added Element
ExplanationOfBenefit.processNote.language ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Change binding strength from extensible to preferred Added Element
ExplanationOfBenefit.benefitPeriod ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.organization ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome
  • deleted Added Element
ExplanationOfBenefit.payee.resourceType ExplanationOfBenefit.processNote.class
  • deleted Added Element
ExplanationOfBenefit.employmentImpacted ExplanationOfBenefit.processNote.type
  • deleted Type changed from code to CodeableConcept
    • ExplanationOfBenefit.hospitalization
  • deleted Change binding strength from required to extensible
ExplanationOfBenefit.item.detail.type ExplanationOfBenefit.processNote.text
  • deleted Type changed from string to markdown
ExplanationOfBenefit.item.detail.subDetail.type ExplanationOfBenefit.processNote.language
ExplanationOfBenefit.addItem.category ExplanationOfBenefit.patient
  • deleted Deleted
ExplanationOfBenefit.addItem.detail.revenue ExplanationOfBenefit.careTeam.responsible
  • deleted Deleted
ExplanationOfBenefit.addItem.detail.category ExplanationOfBenefit.careTeam.qualification
  • deleted Deleted
ExplanationOfBenefit.totalCost ExplanationOfBenefit.diagnosis.packageCode
  • deleted Deleted
ExplanationOfBenefit.unallocDeductable ExplanationOfBenefit.item.subSite
  • deleted Deleted
ExplanationOfBenefit.totalBenefit ExplanationOfBenefit.item.adjudication.value
  • deleted Deleted
ExplanationOfBenefit.benefitBalance.subCategory ExplanationOfBenefit.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). ) for R4B as XML or JSON .

 

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

13.10.3.1 13.10.4.1 Terminology Bindings

ExplanationOfBenefit.payee.type ExplanationOfBenefit.careTeam.role ExplanationOfBenefit.diagnosis.packageCode ExplanationOfBenefit.procedure.type ExplanationOfBenefit.procedure.procedure[x] ExplanationOfBenefit.accident.type ExplanationOfBenefit.item.revenue ExplanationOfBenefit.item.detail.revenue ExplanationOfBenefit.item.detail.subDetail.revenue ExplanationOfBenefit.item.productOrService ExplanationOfBenefit.item.detail.productOrService ExplanationOfBenefit.item.detail.subDetail.productOrService ExplanationOfBenefit.addItem.productOrService ExplanationOfBenefit.addItem.detail.productOrService ExplanationOfBenefit.addItem.detail.subDetail.productOrService ExplanationOfBenefit.item.modifier ExplanationOfBenefit.item.detail.modifier ExplanationOfBenefit.item.detail.subDetail.modifier ExplanationOfBenefit.addItem.modifier ExplanationOfBenefit.addItem.detail.modifier ExplanationOfBenefit.addItem.detail.subDetail.modifier ExplanationOfBenefit.item.location[x] ExplanationOfBenefit.addItem.location[x] ExplanationOfBenefit.item.bodySite ExplanationOfBenefit.addItem.bodySite ExplanationOfBenefit.item.adjudication.category ExplanationOfBenefit.total.category ExplanationOfBenefit.item.adjudication.reason ExplanationOfBenefit.payment.type ExplanationOfBenefit.formCode ExplanationOfBenefit.processNote.language
Path Definition ValueSet Type Reference Documentation
ExplanationOfBenefit.status A code specifying the state of the resource instance. ExplanationOfBenefitStatus Required ExplanationOfBenefitStatus

A code specifying the state of the resource instance.

ExplanationOfBenefit.type The type or discipline-style of the claim. ClaimTypeCodes Extensible ClaimTypeCodes

This value set includes Claim Type codes.

ExplanationOfBenefit.subType A more granular claim typecode. ExampleClaimSubTypeCodes Example ExampleClaimSubTypeCodes

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

ExplanationOfBenefit.use Complete, proposed, exploratory, other. Use Required Use

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

ExplanationOfBenefit.priority The timeliness with which processing is required: stat, normal, deferred. ProcessPriorityCodes Example Preferred http://terminology.hl7.org/CodeSystem/processpriority

This value set includes the financial processing priority codes.

ExplanationOfBenefit.fundsReserveRequested ExplanationOfBenefit.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). FundsReservationCodes Example Preferred

This value set includes funds reservation type codes.

ExplanationOfBenefit.fundsReserve Funds Reservation Codes FundsReservationCodes Preferred

This value set includes funds reservation type codes.

ExplanationOfBenefit.related.relationship Relationship of this claim to a related Claim. ExampleRelatedClaimRelationshipCodes Example ExampleRelatedClaimRelationshipCodes

This value set includes sample Related Claim Relationship codes.

ExplanationOfBenefit.event.type A DatesTypeCodes (a valid code for the party to be reimbursed. from Dates Event Type Codes ) Example

This value set includes sample Dates Type codes.

ExplanationOfBenefit.payee.type Claim ClaimPayeeTypeCodes (a valid code from Payee Type Codes icon ) Example

This value set includes sample Payee Type codes.

ExplanationOfBenefit.outcome The result of the claim processing. ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes ) Required ClaimProcessingCodes

This value set includes Claim Processing Outcome codes.

ExplanationOfBenefit.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Preferred The role codes for the care team members.

This value set includes Claim Adjudication Decision codes.

ExplanationOfBenefit.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.

ExplanationOfBenefit.careTeam.role ClaimCareTeamRoleCodes Preferred

This value set includes sample Claim Care Team Role codes.

ExplanationOfBenefit.careTeam.qualification ExplanationOfBenefit.careTeam.specialty Provider professional qualifications. ExampleProviderQualificationCodes Example ExampleProviderQualificationCodes

This value set includes sample Provider Qualification codes.

ExplanationOfBenefit.supportingInfo.category The valuset used for additional information category codes. ClaimInformationCategoryCodes Example Preferred ClaimInformationCategoryCodes

This value set includes sample Information Category codes.

ExplanationOfBenefit.supportingInfo.code The valuset used for additional information codes. ExceptionCodes Example ExceptionCodes

This value set includes sample Exception codes.

ExplanationOfBenefit.supportingInfo.reason Reason codes for the missing teeth. MissingToothReasonCodes Example MissingToothReasonCodes

This value set includes sample Missing Tooth Reason codes.

ExplanationOfBenefit.diagnosis.diagnosis[x] ICD10 Diagnostic codes. ICD10Codes (a valid code from ICD-10 icon ) Example ICD-10Codes

This value set includes sample ICD-10 codes.

ExplanationOfBenefit.diagnosis.type The type of the diagnosis: admitting, principal, discharge. ExampleDiagnosisTypeCodes Example Preferred ExampleDiagnosisTypeCodes

This value set includes example Diagnosis Type codes.

ExplanationOfBenefit.diagnosis.onAdmission ExampleDiagnosisOnAdmissionCodes Preferred Present

This value set includes example Diagnosis on admission. Admission codes.

ExplanationOfBenefit.procedure.type ExampleProcedureTypeCodes Example Preferred

This value set includes example Procedure Type codes.

ExplanationOfBenefit.procedure.procedure[x] ExampleDiagnosisOnAdmissionCodes ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes ) Example

This value set includes sample ICD-10 Procedure codes.

ExplanationOfBenefit.accident.type ActIncidentCode icon Extensible The DRG

Set of codes associated with indicating the diagnosis. type of incident or accident.

ExplanationOfBenefit.item.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.item.category ExampleDiagnosisRelatedGroupCodes BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.

ExplanationOfBenefit.item.productOrService USCLSCodes Example procedure type

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.modifier ExampleProcedureTypeCodes ModifierTypeCodes Example

This value set includes sample Modifier type codes.

ExplanationOfBenefit.item.programCode ExampleProgramReasonCodes Example ICD10 Procedure

This value set includes sample Program Reason Span codes.

ExplanationOfBenefit.item.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.

ExplanationOfBenefit.item.bodySite.site ICD-10ProcedureCodes OralSiteCodes Example

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

ExplanationOfBenefit.item.bodySite.subSite SurfaceCodes Example Type

This value set includes a smattering of accident: work place, auto, etc. FDI tooth surface codes.

ExplanationOfBenefit.item.reviewOutcome.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Extensible Preferred

This value set includes Claim Adjudication Decision codes.

ExplanationOfBenefit.item.reviewOutcome.reason v3.ActIncidentCode ClaimAdjudicationDecisionReasonCodes Example

This value set includes example Claim Adjudication Decision Reason codes.

ExplanationOfBenefit.item.adjudication.category AdjudicationValueCodes Preferred Codes for

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the revenue or cost centers supplying amounts eligible under the service and/or products. plan, the amount of benefit, copays etc.

ExplanationOfBenefit.item.adjudication.reason AdjudicationReasonCodes Example

This value set includes smattering of Adjudication Reason codes.

ExplanationOfBenefit.item.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.item.category ExplanationOfBenefit.item.detail.category ExplanationOfBenefit.item.detail.subDetail.category ExplanationOfBenefit.benefitBalance.category BenefitCategoryCodes Example

This value set includes examples of Benefit categories such as: oral, medical, vision, oral-basic etc. Category codes.

ExplanationOfBenefit.item.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.productOrServiceEnd BenefitCategoryCodes USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.modifier ModifierTypeCodes Example Allowable service and product

This value set includes sample Modifier type codes.

ExplanationOfBenefit.item.detail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

ExplanationOfBenefit.item.detail.subDetail.revenue USCLSCodes ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.item.detail.subDetail.category BenefitCategoryCodes Example Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

This value set includes examples of Benefit Category codes.

ExplanationOfBenefit.item.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.

ExplanationOfBenefit.item.programCode ExplanationOfBenefit.item.detail.programCode ExplanationOfBenefit.item.detail.subDetail.programCode ExplanationOfBenefit.addItem.programCode ExampleProgramReasonCodes Example

This value set includes sample Program specific reason Reason Span codes.

ExplanationOfBenefit.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.addItem.category ExampleProgramReasonCodes BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.

ExplanationOfBenefit.addItem.productOrService USCLSCodes Example Place where the service is rendered.

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.modifier ExampleServicePlaceCodes ModifierTypeCodes Example

This value set includes sample Modifier type codes.

ExplanationOfBenefit.addItem.programCode ExampleProgramReasonCodes Example The code for the teeth, quadrant, sextant and arch.

This value set includes sample Program Reason Span codes.

ExplanationOfBenefit.addItem.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.

ExplanationOfBenefit.addItem.bodySite.site OralSiteCodes Example

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

ExplanationOfBenefit.item.subSite ExplanationOfBenefit.addItem.subSite ExplanationOfBenefit.addItem.bodySite.subSite SurfaceCodes Example The code for the

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

ExplanationOfBenefit.addItem.detail.revenue ExampleRevenueCenterCodes Example SurfaceCodes

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.addItem.detail.productOrService USCLSCodes Example The adjudication

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.modifier AdjudicationValueCodes ModifierTypeCodes Example

This value set includes sample Modifier type codes.

ExplanationOfBenefit.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example Adjudication reason

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.addItem.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd AdjudicationReasonCodes USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.subDetail.modifier ModifierTypeCodes Example The

This value set includes sample Modifier type (partial, complete) of the payment. codes.

ExplanationOfBenefit.total.category AdjudicationValueCodes Example

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

ExplanationOfBenefit.payment.type ExamplePaymentTypeCodes Preferred

This value set includes example Payment Type codes.

ExplanationOfBenefit.payment.adjustmentReason PaymentAdjustmentReasonCodes Preferred

This value set includes smattering of Payment Adjustment reason Reason codes.

ExplanationOfBenefit.formCode FormCodes Example PaymentAdjustmentReasonCodes

This value set includes a sample set of Forms codes.

ExplanationOfBenefit.processNote.class The forms codes. Example Form Codes
ExplanationOfBenefit.processNote.type NoteType Extensible

The presentation types of notes.

ExplanationOfBenefit.processNote.language AllLanguages (a valid code from Tags for the Identification of Languages icon ) Required

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

  NoteType Common Languages starter
ExplanationOfBenefit.benefitBalance.category A human language. BenefitCategoryCodes Preferred , but limited to AllLanguages Example CommonLanguages

This value set includes examples of Benefit Category codes.

ExplanationOfBenefit.benefitBalance.network Code to classify in or out of network services. NetworkTypeCodes Example NetworkTypeCodes

This value set includes a smattering of Network type codes.

ExplanationOfBenefit.benefitBalance.unit Unit covered/serviced - individual or family. UnitTypeCodes Example UnitTypeCodes

This value set includes a smattering of Unit type codes.

ExplanationOfBenefit.benefitBalance.term Coverage unit - annual, lifetime. BenefitTermCodes Example BenefitTermCodes

This value set includes a smattering of Benefit Term codes.

ExplanationOfBenefit.benefitBalance.financial.type Deductable, visits, co-pay, etc. BenefitTypeCodes Example BenefitTypeCodes

This value set includes a smattering of Benefit type codes.



13.10.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an . element Sequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence,.diagnosis referred to by .diagnosisSequence,.procedure referred to by .procedureSequence,.supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

The .noteNumber element, which appears at the .item,.detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumber s for each of the appropriate line items or details.

13.10.4 13.10.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
care-team reference Member of the CareTeam ExplanationOfBenefit.careTeam.provider
( Practitioner , Organization , PractitionerRole )
claim reference The reference to the claim ExplanationOfBenefit.claim
( Claim )
coverage reference The plan under which the claim was adjudicated ExplanationOfBenefit.insurance.coverage
( 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
( Device )
disposition string The contents of the disposition message ExplanationOfBenefit.disposition
encounter reference Encounters associated with a billed line item ExplanationOfBenefit.item.encounter
( Encounter ) 		27 Resources
enterer reference The party responsible for the entry of the Claim ExplanationOfBenefit.enterer
( Practitioner , Patient , PractitionerRole , RelatedPerson )
facility reference Facility responsible for the goods and services ExplanationOfBenefit.facility
( Organization , Location )
group reference The reference to the group ExplanationOfBenefit.subject.where(resolve() is Group) | ExplanationOfBenefit.item.subject.where(resolve() is Group) | ExplanationOfBenefit.addItem.subject.where(resolve() is Group)
( Group , Patient )
identifier token The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier 59 Resources
item-udi reference UDI associated with a line item product or service ExplanationOfBenefit.item.udi
( Device )
patient reference The reference to the patient ExplanationOfBenefit.patient ExplanationOfBenefit.subject.where(resolve() is Patient) | ExplanationOfBenefit.item.subject.where(resolve() is Patient) | ExplanationOfBenefit.addItem.subject.where(resolve() is Patient)
( Group , Patient ) 		61 Resources
payee reference The party receiving any payment for the Claim ExplanationOfBenefit.payee.party
( Practitioner , Organization , Patient , PractitionerRole , RelatedPerson )
procedure-udi reference UDI associated with a procedure ExplanationOfBenefit.procedure.udi
( Device )
provider reference The reference to the provider ExplanationOfBenefit.provider
( Practitioner , Organization , PractitionerRole )
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
( Device )
subject reference Subject receiving the products or services ExplanationOfBenefit.subject | ExplanationOfBenefit.item.subject | ExplanationOfBenefit.addItem.subject
( Group , Patient )