FHIR Release 3 (STU) CI-Build

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0 . For a full list Continuous Integration Build of available versions, see FHIR (will be incorrect/inconsistent at times).
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13.10 Resource ExplanationOfBenefit - Content

Responsible Owner: Financial Management icon Work Group   Normative 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 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 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 payer or later in a resource which refers to the subject eClaim resource. This also includes how 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 remaining. 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 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 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 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

13.10.2 13.10.4 Resource Content

Structure

0..1 Type Finer grained Period Creation Insurer Responsible organization Treatment Referral 0..1 Reference Claim reference 0..1 Reference complete | error | partial Related file Type of party: Subscriber, Provider, other organization | patient | practitioner | relatedperson BackboneElement positiveInt CodeableConcept Type Reason associated with the information Billing practitioner Claim Care Team Role Codes Type, classification or Specialization Package billing code Procedures Goods and Services Type of service or product Billing Code Service/Product Service List of Adjudication category such as co-pay, eligible, benefit, etc. Type of service or product Billing Code List of Billing Code Net additional List of Billing Code Professional fee List of Added Type of service Billing Code List of Total Cost Identifier of display | print | printoper CodeableConcept Detailed services covered within the type Deductable, visits, benefit amount
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . ExplanationOfBenefit N 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 Σ Number for tracking

. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus Binding: Explanation Of Benefit Status ( Required )
. . type . statusReason Σ 0..1 string Reason for status change
... type Σ 1..1 CodeableConcept Category or discipline
Example Binding: Claim Type Codes ( Required Extensible )
. . . subType 0..* 0..1 CodeableConcept More granular claim type information
Binding: Example Claim SubType Codes ( Example )
. . patient . use Σ 0..1 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
... subject Σ 1..1 Reference ( Patient | Group ) The subject recipient(s) of the Products products and Services services
. . . billablePeriod Σ 0..1 Period Relevant time frame for charge submission the claim
. . . created Σ 0..1 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 the EOB reimbursement
. . . provider Σ 0..1 Reference ( Practitioner ) Responsible provider for the claim organization 0..1 Reference | PractitionerRole ( | Organization ) Party responsible for the claim
. . referral . priority 0..1 Reference ( ReferralRequest ) 0..1 facility CodeableConcept Desired processing urgency
Binding: Process Priority Codes ( Location Preferred )
Servicing Facility
. . claim . fundsReserveRequested 0..1 Reference ( Claim ) 0..1 claimResponse CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes ( ClaimResponse Preferred )
Claim response reference
. . . outcome fundsReserve 0..1 CodeableConcept Funds reserved status
Claim Processing Binding: Funds Reservation Codes ( Example Preferred ) disposition 0..1 string
Disposition Message
. . . related 0..* BackboneElement Prior or corollary claims
Related Claims which may be revelant to processing this claim
. . . . 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..1 0..* BackboneElement Event information

Party to be paid any benefits payable
. . . . type 0..1 1..1 CodeableConcept Specific event
Claim Payee Binding: Dates Type Codes ( Example )
. . . . when[x] 1..1 Occurance date or period
. . . . resourceType . whenDateTime dateTime
. . . . . whenPeriod Period
. . . payee 0..1 BackboneElement Recipient of benefits payable
.... type 0..1 CodeableConcept Category of recipient
PayeeResourceType Binding: Claim Payee Type Codes ( Required Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
Party to receive the payable
. . information . referral 0..1 0..* Reference ( ServiceRequest ) Treatment Referral
. . . encounter 0..* Exceptions, special considerations, Reference ( Encounter ) Encounters associated with the condition, situation, prior or concurrent issues listed treatments

. . sequence . facility 0..1 1..1 Reference ( Location | Organization ) Servicing Facility
. . . claim 0..1 Reference ( Claim ) Claim reference
Information instance identifier
. . category . claimResponse 0..1 Reference ( ClaimResponse ) Claim response reference
1..1
. . . outcome General class of information Σ 1..1 code queued | complete | error | partial
Binding: Claim Information Category Processing Codes ( Example Required )
. . code . decision Σ 0..1 CodeableConcept Result of information the adjudication
Exception Binding: Claim Adjudication Decision Codes ( Example Preferred )
. . timing[x] . disposition 0..1 string Disposition Message
When it occurred
. . timingDate . preAuthRef 0..* date string Preauthorization reference

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

. . value[x] . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
Additional Data or supporting information
. . . careTeam valueString 0..* string BackboneElement Care Team members

. . . valueQuantity . sequence 1..1 Quantity positiveInt Order of care team
. . . valueAttachment . provider 1..1 Attachment Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . role valueReference 0..1 CodeableConcept Reference Function within the team
Binding: Claim Care Team Role Codes ( Any Preferred )
. . . . reason specialty 0..1 Coding CodeableConcept Practitioner or provider specialization
Missing Tooth Reason Binding: Example Provider Qualification Codes ( Example )
. . careTeam . supportingInfo 0..* BackboneElement Supporting information
Care Team members
. . . . sequence 1..1 positiveInt Information instance identifier
Number to covey order of careteam
. . . provider . category 1..1 CodeableConcept Reference Classification of the supplied information
Binding: Claim Information Category Codes ( Practitioner | Organization Preferred )
Member of the Care Team
. . . responsible . code 0..1 CodeableConcept boolean Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . role . timingDateTime dateTime
. . . . . timingPeriod Period
. . . . . timingTiming 0..1 CodeableConcept Timing Role on the team
. . . . value[x] ( Example ) 0..1 * Data to be provided
. . . . qualification reason 0..1 CodeableConcept Coding Explanation for the information
Example Provider Qualification Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information
List of Diagnosis
. . . . sequence 1..1 positiveInt Diagnosis instance identifier
Number to covey order of diagnosis
. . . . diagnosis[x] 1..1 Patient's diagnosis 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 )

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

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

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Patient's list of procedures performed 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..1 0..* BackboneElement Patient insurance information

Insurance or medical plan
. . . coverage . focal Σ 0..1 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . preAuthRef 0..* string Prior authorization reference number
Pre-Authorization/Determination Reference
. . . accident 0..1 BackboneElement Details of an accident the event
. . . . date 0..1 date When the accident incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon ( Required Extensible )
. . . . location[x] 0..1 Where the event occurred
Accident Place
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . employmentImpacted . patientPaid 0..1 Period Money Paid by the patient
Period unable to work
. . hospitalization . item 0..1 0..* Period BackboneElement Product or service provided

Period in hospital
. . . item . sequence 0..* 1..1 BackboneElement positiveInt Item instance identifier
. . . . sequence careTeamSequence 1..1 0..* positiveInt Applicable care team members

Service instance
. . . careTeamLinkId . diagnosisSequence 0..* positiveInt Applicable careteam members diagnoses

. . . . diagnosisLinkId procedureSequence 0..* positiveInt Applicable diagnoses procedures

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

. . . informationLinkId . traceNumber 0..* Identifier positiveInt Number for tracking

.... subject Applicable exception 0..1 Reference ( Patient | Group ) The recipient of the products and supporting information services
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory Category Codes ( Example )
. . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of Service 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 )
. . . . quantity patientPaid 0..1 Money Paid by the patient
.... quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier

. . . . bodySite 0..* BackboneElement 0..1 Anatomical location

CodeableConcept
. . . . . site Service 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 which apply

. . . . 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 adjudication outcome
Binding: Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . . quantity 0..1 Quantity Non-monitary value
. . . . . value decisionDate 0..1 decimal dateTime When was adjudication performed
Non-monitory value
. . . . detail 0..* BackboneElement Additional items

. . . . . sequence 1..1 positiveInt Product or service provided
Service instance
. . . . type . traceNumber 1..1 0..* CodeableConcept Identifier Number for tracking
Group or type of product or service
ActInvoiceGroupCode ( Required )
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory Category Codes ( Example )
. . . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

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

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

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

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

. . . . . . sequence 1..1 positiveInt Product or service provided
Service instance
. . . . . . type traceNumber 1..1 0..* CodeableConcept Identifier Number for tracking
Type of product or service
ActInvoiceGroupCode ( Required )
. . . . . . 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 )
Type of service
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

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

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

. . . . . . reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details
Language if different from the resource
. . . addItem 0..* BackboneElement Insurer added line items

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

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

.... subDetailSequence 0..* positiveInt Subdetail sequence number
Service instances
. . . revenue . 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

.... 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 )
Type of service
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . service 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 )

. . . fee . 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 Product services
.... unitPrice 0..1 Money Fee, charge or cost per item
. . . . noteNumber factor 0..1 decimal Price scaling factor
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... 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 which apply

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

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

. . . . . revenue traceNumber 0..* Identifier 0..1 Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category productOrService 0..1 CodeableConcept Billing, service, product, or product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . service . 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 )

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

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

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

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

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

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

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

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

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

Payment (if paid)
. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
... . type amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Payment Details
.... type 0..1 CodeableConcept Partial or Complete complete payment
Binding: Example Payment Type Codes ( Example Preferred )
. . . . adjustment 0..1 Money Payment adjustment for non-Claim non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the non-claim adjustment variance
Binding: Payment Adjustment Reason Codes ( Example Preferred )
. . . . date 0..1 date Expected date of Payment payment
. . . . amount 0..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment instrument
. . . form formCode 0..1 CodeableConcept Printed Form Identifier form identifier
Binding: Form Codes ( Example )
. . . form 0..1 Attachment Printed reference or actual form
.. . processNote 0..* BackboneElement Note concerning adjudication
Processing notes
. . . . class 0..1 CodeableConcept Business kind of note
Binding: ProcessNoteClass ( Example )
. . . . number 0..1 positiveInt Note instance identifier
Sequence number for this note
. . . . type 0..1 CodeableConcept Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 0..1 string markdown Note explanitory explanatory text
. . . . language 0..1 CodeableConcept Language if different from of the resource text
Common Languages ( Extensible but limited to Binding: All Languages ( Required ) benefitBalance Balance by Benefit Category
Additional Bindings Purpose
Common Languages 0..* BackboneElement Starter

. . . category benefitPeriod 0..1 Period 1..1 When the benefits are applicable
. . . benefitBalance Type of services covered 0..* BackboneElement Balance by Benefit Category Codes ( Example )

. . . . subCategory category 0..1 1..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory 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

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UML Diagram ( Legend )

ExplanationOfBenefit ( DomainResource ) The EOB Business Identifier 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 [0..1] [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, eg, e.g. oral, pharmacy, vision, insitutional, institutional, professional type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim (Strength=Required) null (Strength=Extensible) Example Claim Type ! ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granulat claim typecode null (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Patient Resource A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the 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 under the identified policy and report back what the Benefit payable would be had the services actually been provided patient use : code [1..1] « null (Strength=Required) Use ! » The 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 subject : Reference [0..1] [1..1] « Patient | Group » The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the EOB this resource was created created : dateTime [0..1] [1..1] The person Individual who created the explanation of benefit claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The insurer which is party responsible for the explanation of benefit authorization, adjudication and reimbursement insurer : Reference [0..1] « Organization » The provider which is responsible for the claim claim, predetermination or preauthorization provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The provider provider-required urgency of processing the request. Typical values include: stat, normal deferred priority : CodeableConcept [0..1] « null (Strength=Preferred) ProcessPriorityCodes ? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserveRequested : CodeableConcept [0..1] « null (Strength=Preferred) 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] « null (Strength=Preferred) FundsReservationCodes ? » Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is responsible 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 claim dispensing of pharmacy services, medications or products organization originalPrescription : Reference [0..1] Organization « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » The referral resource which lists information received by the date, practitioner, reason and other claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] ReferralRequest « 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: invoice number, instance of the adjudication request: claim number, pre-determination predetermination or pre-authorization number preauthorization claim : Reference [0..1] « Claim » The business identifier for the instance: invoice number, claim number, pre-determination instance of the adjudication response: claim, predetermination or pre-authorization number preauthorization response claimResponse : Reference [0..1] « ClaimResponse » Processing The outcome errror, partial of the claim, predetermination, or complete preauthorization processing outcome : CodeableConcept code [0..1] [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing (Strength=Example) claim, predetermination, or preauthorization adjudication Claim Processing decision ?? : CodeableConcept [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A human readable description of the status of the adjudication disposition : string [0..1] Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference [0..1] MedicationRequest | VisionPrescription Original prescription which has been superceded by this prescription to support from the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication Insurer which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication used in later communications which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' originalPrescription : Reference [0..1] MedicationRequest Precedence (primary, secondary, etc.) refers to this adjudication precedence preAuthRef : positiveInt string [0..1] [0..*] The start and optional end dates of when timeframe during which the patient was precluded from working due supplied preauthorization reference may be quoted on claims to obtain the treatable condition(s) adjudication as provided employmentImpacted preAuthRefPeriod : Period [0..1] [0..*] The start A package billing code or bundle code used to group products and optional end dates of when the patient was confined services to a treatment center particular health condition (such as heart attack) which is based on a predetermined grouping code system hospitalization diagnosisRelatedGroup : Period CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » The total cost This indicates the relative order of a series of EOBs related to different coverages for the same suite of services reported totalCost precedence : Money positiveInt [0..1] The amount of deductable applied which was not allocated paid by the patient, in total at the claim claim level or specifically for the item and detail level, to any particular service line the provider for goods and services unallocDeductable patientPaid : Money [0..1] Total amount of benefit payable (Equal to sum of A code for the Benefit amounts from all detail lines and additions less form to be used for printing the Unallocated Deductable) content totalBenefit formCode : Money CodeableConcept [0..1] « null (Strength=Example) FormCodes ?? » The form to be used actual form, by reference or inclusion, for printing the content or an EOB form : CodeableConcept Attachment [0..1] The forms codes. (Strength=Example) term of the benefits documented in this response Form benefitPeriod ?? : Period [0..1] RelatedClaim Other claims which are related Reference to this claim such a related Claim or ExplanationOfBenefit as prior a representation of a claim versions or for related services claim : Reference [0..1] « Claim | ExplanationOfBenefit » For example prior or umbrella A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim null (Strength=Example) Example Related Claim Relatio... ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # 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 | patient | practitioner | relatedperson to whom any payment will be made resourceType party : CodeableConcept Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam The type of payee Resource (Strength=Required) A number to uniquely identify care team entries PayeeResourceType ! sequence : positiveInt [1..1] Party to be reimbursed: Subscriber, provider, other Member of the team who provided the product or service party provider : Reference [0..1] [1..1] « Practitioner | Organization PractitionerRole | Patient Organization | » RelatedPerson The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « null (Strength=Preferred) ClaimCareTeamRoleCodes ? » The specialization of the practitioner or provider which is applicable for this service specialty : CodeableConcept [0..1] « null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation Sequence of the information element which serves A number to provide a link 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) Claim Information Category ClaimInformationCategoryCodes ?? ? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) Exception 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] string | Quantity | Attachment | Reference ( Any ) For example, provides Provides the reason for: in the additional stay, or missing tooth or any other 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) Missing Tooth Reason MissingToothReasonCodes ?? » CareTeam Diagnosis Sequence of careteam which serves A number to order and provide a link uniquely identify diagnosis entries sequence : positiveInt [1..1] The members nature of the team who provided the overall service provider : Reference [1..1] Practitioner | Organization The practitioner who is billing and responsible for the claimed services rendered to the patient responsible : boolean [0..1] The lead, assisting illness or supervising practitioner and their discipline if problem in a multidisiplinary team role : CodeableConcept [0..1] The role codes for the care team members. (Strength=Example) Claim Care Team Role ?? The qualification which is applicable for this service qualification : CodeableConcept [0..1] Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? Diagnosis Sequence of diagnosis which serves to provide coded form or as a link sequence : positiveInt [1..1] The diagnosis reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes null (Strength=Example) ICD-10 ICD10Codes ?? » The type of When the Diagnosis, for example: admitting, primary, secondary, discharge condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example) null (Strength=Preferred) Example Diagnosis Type ExampleDiagnosisTypeCodes ?? ? » The package billing code, for example DRG, based on Indication of whether the assigned grouping code system diagnosis was present on admission to a facility packageCode onAdmission : CodeableConcept [0..1] « The DRG codes associated with the diagnosis (Strength=Example) null (Strength=Preferred) Example Diagnosis Related Gro... ExampleDiagnosisOnAdmissionCo... ?? ? » Procedure Sequence of procedures which serves A number to order and provide a link uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « null (Strength=Preferred) ExampleProcedureTypeCodes ? » Date and optionally time the procedure was performed date : dateTime [0..1] The procedure 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-10 Procedure 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 program or plan identification, underwriter or payor 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 [0..1] [1..1] « Coverage » A list of references from Reference numbers previously provided by the Insurer insurer to which these the provider to be quoted on subsequent claims containing services pertain or products related to the prior authorization preAuthRef : string [0..*] Accident Date of an accident which these event related to the products and services are addressing contained in the claim date : date [0..1] Type The type or context of accident: work, auto, etc 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. (Strength=Required) null (Strength=Extensible) ActIncidentCode ! + » Where The physical location of the accident occurred event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A service line number to uniquely identify item entries sequence : positiveInt [1..1] Careteam applicable for Care team members related to this service or product line careTeamLinkId careTeamSequence : positiveInt [0..*] Diagnosis Diagnoses applicable for this service or product line diagnosisLinkId diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product line procedureLinkId procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable applicable for this service or product line informationLinkId 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 reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the type item. This element may be the start of thing being grouped eg. 'glasses' a range of .productOrService codes used in conjunction with .productOrServiceEnd or 'compound' it may be a solo element where .productOrServiceEnd is not used service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier 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 type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The date or dates when the enclosed suite of services were 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) Example Service Place 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 node group then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: unit Quantity * group (if a grouper) or the line item. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of 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) etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch null (Strength=Example) Oral Site OralSiteCodes ?? » A region or surface of the site, eg. bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations null (Strength=Example) Surface 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..*] Encounter [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A list The reasons for the result of note references to the notes provided below claim, predetermination, or preauthorization adjudication noteNumber reason : positiveInt CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Adjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) null (Strength=Preferred) Adjudication Value AdjudicationValueCodes ?? ? » Adjudication reason such as limit reached 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) Adjudication Reason AdjudicationReasonCodes ?? » Monitory Monetary amount associated with the code category amount : Money [0..1] A non-monetary value for example a percentage. 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 service line number claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] The type of product Trace number for tracking purposes. May be defined at the jurisdiction level or service between trading partners type traceNumber : CodeableConcept Identifier [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! [0..*] The type of reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the type item. This element may be the start of thing being grouped eg. 'glasses' a range of .productOrService codes used in conjunction with .productOrServiceEnd or 'compound' it may be a solo element where .productOrServiceEnd is not used service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier productOrServiceEnd : CodeableConcept [0..*] [0..1] « null (Strength=Example) USCLSCodes ?? » Item type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason 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 node group then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: group (if a grouper) or the line item.detail. Net = unit Quantity price * unit Price (Cost per Point) quantity * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A service line number claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] The type of product Trace number for tracking purposes. May be defined at the jurisdiction level or service between trading partners type traceNumber : CodeableConcept Identifier [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! [0..*] The type of reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » A When the value is a group code to indicate then this item collects a set of related item details, otherwise this contains the Professional Service product, service, drug or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) other billing code for the 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 service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier productOrServiceEnd : CodeableConcept [0..*] [0..1] « null (Strength=Example) USCLSCodes ?? » Item type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason 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] The If the item is not a group then this is the fee for an addittional service or the product or charge 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: unit Quantity * line item.detail.subDetail. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem List of input service Claim items which this service line is intended to replace sequenceLinkId itemSequence : positiveInt [0..*] The type sequence number of reveneu 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 cost center providing between trading partners traceNumber : Identifier [0..*] The party to whom the product professional services and/or service products have been supplied or are being considered and for whom actual for facast reimbursement is sought revenue subject : CodeableConcept Reference [0..1] « Patient | Group » Codes 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 centers supplying center providing the service product and/or products. service revenue : CodeableConcept [0..1] « null (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, group code then use this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the Professional Service item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If it may be a grouping item then use solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [0..1] « 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 indicate convey the type start of thing being grouped eg. 'glasses' or 'compound' the range. Typically this value may be used only with preauthorizations and not with claims service productOrServiceEnd : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification Request or modifiers codes, eg Referral for Oral whether the treatment is cosmetic Goods or associated with TMJ, Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « null (Strength=Example) ModifierTypeCodes ?? » Item type or modifiers codes, eg for Oral whether Identifies the treatment is cosmetic program under which this may be recovered programCode : CodeableConcept [0..*] « null (Strength=Example) ExampleProgramReasonCodes ?? » The date or associated with TMJ, dates when the service or an appliance product was lost supplied, performed or stolen. completed serviced[x] : DataType [0..1] « date | Period » Where the product or service was provided location[x] : DataType [0..1] « CodeableConcept | Address | Reference ( Location ); null (Strength=Example) Modifier type ExampleServicePlaceCodes ?? » The fee charged amount paid by the patient, in total at the claim claim level or specifically for the professional 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 list real number that represents a multiplier used in determining the overall value of note references 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 total of taxes applicable for this product or 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 provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemsDetail AddedItemBodySite Physical service site on the patient (limb, tooth, etc.) site : CodeableReference [1..*] « BodyStructure ; null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « null (Strength=Example) SurfaceCodes ?? » AddedItemDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » Codes for When the revenue value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or cost centers supplying other billing code for the service and/or products. 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 [0..1] « null (Strength=Example) Example Revenue Center USCLSCodes ?? » Health Care Service Type Codes to identify This contains the classification end of service a range of product, service, drug or benefits 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 not with claims category productOrServiceEnd : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory USCLSCodes ?? » A code Item typification or modifiers codes to indicate convey additional context for the Professional Service product or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service modifier : CodeableConcept [0..*] « 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] Allowable The number of repetitions of a service and or product codes (Strength=Example) USCLS quantity ?? : Quantity ( SimpleQuantity ) [0..1] Item typification or modifiers codes, eg If the item is not a group then this is the fee for Oral whether the treatment product or service, otherwise this is cosmetic 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 associated with TMJ, surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The total of taxes applicable for this product or service tax : Money [0..1] The total amount claimed for medical whether the treatment was outside the clinic group (if a grouper) or out the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of office hours this item modifier noteNumber : CodeableConcept positiveInt [0..*] AddedItemDetailSubDetail Item Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or modifiers codes, eg 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 item details, otherwise this contains the product, service, drug or other billing code for Oral whether the treatment 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 cosmetic not used productOrService : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or associated 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 TMJ, preauthorizations and not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or an appliance was lost modifiers codes to convey additional context for the product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » The fee charged amount paid by the patient, in total at the claim claim level or specifically for the professional 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 list real number that represents a multiplier used in determining the overall value of note references 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 total of taxes applicable for this product or 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 provided 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] « 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 claim benefits payable type : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example) null (Strength=Preferred) Example Payment Type ExamplePaymentTypeCodes ?? ? » Adjustment Total amount of all adjustments to the this payment of included in this transaction which is are not related to adjudication of this transaction 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) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? ? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Payable Benefits payable less any payment adjustment amount : Money [0..1] Payment identifer Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note An integer associated with each A code to indicate the business purpose of the note which may be referred class : CodeableConcept [0..1] « null (Strength=Example) ProcessNoteClass?? » A number to from each service line item uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note purpose: Print/Display text type : CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The note text explanation or description associated with the processing text : string markdown [0..1] The ISO-639-1 alpha 2 A code in lower case for to define the language, optionally followed by a hyphen and language used in the ISO-3166-1 alpha 2 code for text of the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English note language : CodeableConcept [0..1] « A human language. (Strength=Extensible) null (Strength=Required) Common Languages + AllLanguages ! » BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc 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 etc. (Strength=Example) Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » True if the indicated class of service is excluded from the plan, missing or False indicated indicates the product or service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit, for example MED01, or DENT2 benefit name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' benefit or services covered description : string [0..1] Network designation 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) Network Type NetworkTypeCodes ?? » Unit designation: 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) Unit Type UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime null (Strength=Example) Benefit Term BenefitTermCodes ?? » Benefit Deductable, visits, Classification of benefit amount being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. null (Strength=Example) Benefit Type BenefitTypeCodes ?? » Benefits allowed The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » Benefits used 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 claim versions 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. Often there are mutiple jurisdiction specific valuesets which are required issues information supportingInfo [0..*] The members of Information about diagnoses relevant to the team who provided claim items diagnosis [0..*] Procedures performed on the overall service as well as their role and whether responsible patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and qualifications services specified on the claim careTeam insurance [0..*] Ordered list Details of patient diagnosis for a accident which care resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is sought performed or applies diagnosis bodySite [0..*] Ordered list The high-level results of patient procedures performed to support the adjudication if adjudication has been performed procedure reviewOutcome [0..*] [0..1] Financial instrument by which payment information for health care 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 insurance adjudication [0..1] [0..*] An accident which resulted in The high-level results of the need for healthcare services adjudication if adjudication has been performed accident reviewOutcome [0..1] The adjudications adjudication results adjudication [0..*] The adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..*] [0..1] The adjudications adjudication results adjudication [0..*] Third tier Third-tier of goods and services subDetail [0..*] Second tier Second-tier of goods and services detail [0..*] First tier A claim line. Either a simple (a product or service) or a 'group' of goods and services 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 adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The second tier 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 detail subDetail [0..*] The first tier second-tier service adjudications for payor payer added services detail [0..*] The first-tier service adjudications for 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 claim if adjudication of the claim has been paid payment [0..1] Note text 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>
 <
 <</type>
 <</subType>
 <</patient>
 <</billablePeriod>
 <
 <</enterer>
 <</insurer>
 <</provider>
 <</organization>
 <</referral>
 <</facility>
 <</claim>
 <</claimResponse>
 <</outcome>
 <
 <
  <</claim>
  <</relationship>
  <</reference>

 <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>
 <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><!-- 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><!-- 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>
 <
  <</type>
  <</resourceType>
  <</party>

 <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><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <
  <
  <</category>
  <</code>
  <</timing[x]>
  <</value[x]>
  <</reason>
 </information>
 <
  <
  <</provider>
  <
  <</role>
  <</qualification>

 <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><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <
  <
  <</diagnosis[x]>
  <</type>
  <</packageCode>

 <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]><!-- 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>

 </diagnosis>
 <
  <
  <
  <</procedure[x]>

 <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>
 <
 <
  <</coverage>
  <

 <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>
 <
  <
  <</type>
  <</location[x]>

 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <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>
 <</employmentImpacted>
 <</hospitalization>
 <
  <
  <
  <
  <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</programCode>
  <</serviced[x]>
  <</location[x]>
  <</quantity>
  <</unitPrice>
  <
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</encounter>
  <
  <
   <</category>
   <</reason>
   <</amount>
   <

 <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><!-- 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 -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <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>
  <
   <
   <</type>
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</programCode>
   <</quantity>
   <</unitPrice>
   <
   <</net>
   <</udi>
   <
   <</adjudication>
   <
    <
    <</type>
    <</revenue>
    <</category>
    <</service>
    <</modifier>
    <</programCode>
    <</quantity>
    <</unitPrice>
    <
    <</net>
    <</udi>
    <
    <</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><!-- 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 -->
   <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><!-- 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 -->
    <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>
 <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</fee>
  <
  <</adjudication>
  <
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</fee>
   <
   <</adjudication>

 <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 -->
  <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 -->
  <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>
  <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 -->
   <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>
   <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 -->
    <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>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <
  <</type>
  <</adjustment>
  <</adjustmentReason>
  <
  <</amount>
  <</identifier>

 <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>
 <</form>
 <
  <
  <</type>
  <
  <</language>

 <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 -->
  <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>
  <</subCategory>
  <
  <
  <
  <</network>
  <</unit>
  <</term>

  <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>
   <</allowed[x]>
   <</used[x]>

   <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" : "",

  "resourceType" : "ExplanationOfBenefit",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
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  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "

  "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

      }]
    }]
  }],
  "
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      "
      "
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      "
      "
      "
      "

  "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:
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    fhir:
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  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ];
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 4
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    # . One of these 2
      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:
    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:
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      fhir:
    ], ...;
    fhir:
      fhir:
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      fhir:
      fhir:
      fhir:
      fhir:
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      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:
    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 DSTU2 from both R4 and R4B

ExplanationOfBenefit.status Added Element ExplanationOfBenefit.type
ExplanationOfBenefit Added Element
ExplanationOfBenefit.subType ExplanationOfBenefit.traceNumber
  • Added Element
ExplanationOfBenefit.patient ExplanationOfBenefit.statusReason
  • Added Element
ExplanationOfBenefit.billablePeriod ExplanationOfBenefit.subject
  • Added Mandatory Element
ExplanationOfBenefit.enterer
  • Type Reference: Added Element Target Types Patient, RelatedPerson
ExplanationOfBenefit.insurer
  • Added Element ExplanationOfBenefit.provider Added Element ExplanationOfBenefit.referral Added Element ExplanationOfBenefit.facility Added Element ExplanationOfBenefit.claim Added Element ExplanationOfBenefit.claimResponse Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.outcome ExplanationOfBenefit.provider
  • Type Min Cardinality changed from code 1 to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) ExplanationOfBenefit.related Added Element 0
ExplanationOfBenefit.related.claim
  • Type Reference: Added Element ExplanationOfBenefit.related.relationship Added Element ExplanationOfBenefit.related.reference Added Element Target Type ExplanationOfBenefit
ExplanationOfBenefit.prescription
  • Type Reference: Added Element Target Types DeviceRequest, ServiceRequest
ExplanationOfBenefit.originalPrescription
  • Type Reference: Added Element ExplanationOfBenefit.payee Added Element ExplanationOfBenefit.payee.type Added Element ExplanationOfBenefit.payee.resourceType Added Element ExplanationOfBenefit.payee.party Added Element ExplanationOfBenefit.information Added Element ExplanationOfBenefit.information.sequence Added Element ExplanationOfBenefit.information.category Added Element ExplanationOfBenefit.information.code Added Element ExplanationOfBenefit.information.timing[x] Added Element ExplanationOfBenefit.information.value[x] Added Element ExplanationOfBenefit.information.reason Added Element ExplanationOfBenefit.careTeam Added Element ExplanationOfBenefit.careTeam.sequence Added Element ExplanationOfBenefit.careTeam.provider Added Element ExplanationOfBenefit.careTeam.responsible Added Element Target Types DeviceRequest, ServiceRequest, VisionPrescription
ExplanationOfBenefit.careTeam.role ExplanationOfBenefit.event
  • Added Element
ExplanationOfBenefit.careTeam.qualification ExplanationOfBenefit.event.type
  • Added Mandatory Element
ExplanationOfBenefit.diagnosis ExplanationOfBenefit.event.when[x]
  • Added Mandatory Element
ExplanationOfBenefit.diagnosis.sequence ExplanationOfBenefit.encounter
  • Added Element
ExplanationOfBenefit.diagnosis.diagnosis[x] ExplanationOfBenefit.facility
  • Type Reference: Added Element Target Type Organization
ExplanationOfBenefit.diagnosis.type ExplanationOfBenefit.outcome
ExplanationOfBenefit.diagnosis.packageCode ExplanationOfBenefit.decision
  • Added Element
ExplanationOfBenefit.procedure ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.procedure.sequence ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.procedure.date ExplanationOfBenefit.supportingInfo.timing[x]
  • Added Element Add Types dateTime, Timing
    • ExplanationOfBenefit.procedure.procedure[x]
  • Added Element Remove Type date
ExplanationOfBenefit.precedence ExplanationOfBenefit.supportingInfo.value[x]
  • Added Element 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.insurance
  • Added Element ExplanationOfBenefit.insurance.coverage Added Element ExplanationOfBenefit.insurance.preAuthRef Added Element ExplanationOfBenefit.accident Added Element ExplanationOfBenefit.accident.date Added Element ExplanationOfBenefit.accident.type Added Element ExplanationOfBenefit.accident.location[x] Added Element ExplanationOfBenefit.employmentImpacted Added Element ExplanationOfBenefit.hospitalization Added Element ExplanationOfBenefit.item Added Element ExplanationOfBenefit.item.sequence Added Element ExplanationOfBenefit.item.careTeamLinkId Added Element ExplanationOfBenefit.item.diagnosisLinkId Added Element ExplanationOfBenefit.item.procedureLinkId Added Element ExplanationOfBenefit.item.informationLinkId Added Element ExplanationOfBenefit.item.revenue Added Element ExplanationOfBenefit.item.category Added Element ExplanationOfBenefit.item.service Added Element ExplanationOfBenefit.item.modifier Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.programCode ExplanationOfBenefit.patientPaid
  • Added Element
ExplanationOfBenefit.item.serviced[x] ExplanationOfBenefit.item.traceNumber
  • Added Element
ExplanationOfBenefit.item.location[x] ExplanationOfBenefit.item.subject
  • Added Element
ExplanationOfBenefit.item.quantity ExplanationOfBenefit.item.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.unitPrice ExplanationOfBenefit.item.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.factor ExplanationOfBenefit.item.request
  • Added Element
ExplanationOfBenefit.item.net ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.item.udi ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Added Element ExplanationOfBenefit.item.subSite Added Element ExplanationOfBenefit.item.encounter Added Element ExplanationOfBenefit.item.noteNumber Added Element ExplanationOfBenefit.item.adjudication Added Element ExplanationOfBenefit.item.adjudication.category Added Element ExplanationOfBenefit.item.adjudication.reason Added Element ExplanationOfBenefit.item.adjudication.amount Added Element ExplanationOfBenefit.item.adjudication.value Added Element ExplanationOfBenefit.item.detail Added Element ExplanationOfBenefit.item.detail.sequence Added Element ExplanationOfBenefit.item.detail.type Added Element ExplanationOfBenefit.item.detail.revenue Added Element ExplanationOfBenefit.item.detail.category Added Element ExplanationOfBenefit.item.detail.service Added Element ExplanationOfBenefit.item.detail.modifier Added Element Max Cardinality changed from 1 to *
    • ExplanationOfBenefit.item.detail.programCode
  • Added Element Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.item.detail.quantity ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.item.detail.unitPrice ExplanationOfBenefit.item.bodySite.subSite
  • Added Element
ExplanationOfBenefit.item.detail.factor ExplanationOfBenefit.item.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.net ExplanationOfBenefit.item.reviewOutcome.decision
  • Added Element
ExplanationOfBenefit.item.detail.udi ExplanationOfBenefit.item.reviewOutcome.reason
  • Added Element
ExplanationOfBenefit.item.detail.noteNumber ExplanationOfBenefit.item.reviewOutcome.preAuthRef
  • Added Element
ExplanationOfBenefit.item.detail.adjudication ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod
  • Added Element
ExplanationOfBenefit.item.detail.subDetail ExplanationOfBenefit.item.adjudication.quantity
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.sequence ExplanationOfBenefit.item.adjudication.decisionDate
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.type ExplanationOfBenefit.item.detail.traceNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.revenue ExplanationOfBenefit.item.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.category ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.service ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.modifier ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.programCode ExplanationOfBenefit.item.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.quantity ExplanationOfBenefit.item.detail.subDetail.traceNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.unitPrice ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.factor ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.net ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.udi ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.noteNumber ExplanationOfBenefit.item.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.adjudication ExplanationOfBenefit.addItem.traceNumber
  • Added Element
ExplanationOfBenefit.addItem ExplanationOfBenefit.addItem.subject
  • Added Element
ExplanationOfBenefit.addItem.sequenceLinkId ExplanationOfBenefit.addItem.informationSequence
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.service ExplanationOfBenefit.addItem.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.modifier ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.fee ExplanationOfBenefit.addItem.request
  • Added Element
ExplanationOfBenefit.addItem.noteNumber ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.adjudication ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.detail ExplanationOfBenefit.addItem.bodySite
  • Added Element Max Cardinality changed from 1 to *
    • ExplanationOfBenefit.addItem.detail.revenue
  • Added Element Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.detail.category ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.detail.service ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.modifier ExplanationOfBenefit.addItem.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.detail.fee ExplanationOfBenefit.addItem.detail.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.noteNumber ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.adjudication ExplanationOfBenefit.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.totalCost ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.unallocDeductable ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.totalBenefit ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.payment ExplanationOfBenefit.addItem.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.payment.type ExplanationOfBenefit.addItem.detail.subDetail.traceNumber
  • Added Element
ExplanationOfBenefit.payment.adjustment ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.payment.adjustmentReason ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.payment.date ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.payment.amount ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.payment.identifier ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.form ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.processNote ExplanationOfBenefit.processNote.class
  • Added Element
ExplanationOfBenefit.processNote.number ExplanationOfBenefit.processNote.type
  • Added Element Type changed from code to CodeableConcept
    • ExplanationOfBenefit.processNote.type
  • Added Element Change binding strength from required to extensible
ExplanationOfBenefit.processNote.text
  • Added Element Type changed from string to markdown
ExplanationOfBenefit.processNote.language
  • Added Element ExplanationOfBenefit.benefitBalance Added Element ExplanationOfBenefit.benefitBalance.category Added Element ExplanationOfBenefit.benefitBalance.subCategory Added Element ExplanationOfBenefit.benefitBalance.excluded Added Element ExplanationOfBenefit.benefitBalance.name Added Element ExplanationOfBenefit.benefitBalance.description Added Element ExplanationOfBenefit.benefitBalance.network Added Element ExplanationOfBenefit.benefitBalance.unit Added Element ExplanationOfBenefit.benefitBalance.term Added Element Change binding strength from preferred to required
    • ExplanationOfBenefit.benefitBalance.financial
  • Added Element Change value set from Common Languages to All Languages
    • ExplanationOfBenefit.benefitBalance.financial.type
  • Added Element Change max value set from All Languages to none
ExplanationOfBenefit.benefitBalance.financial.allowed[x] ExplanationOfBenefit.patient
  • Added Element Deleted
ExplanationOfBenefit.benefitBalance.financial.used[x] ExplanationOfBenefit.careTeam.responsible
  • Added Element Deleted
ExplanationOfBenefit.request ExplanationOfBenefit.careTeam.qualification
  • deleted Deleted
ExplanationOfBenefit.ruleset ExplanationOfBenefit.diagnosis.packageCode
  • deleted Deleted
ExplanationOfBenefit.originalRuleset ExplanationOfBenefit.item.subSite
  • deleted Deleted
ExplanationOfBenefit.requestProvider ExplanationOfBenefit.item.adjudication.value
  • deleted Deleted
ExplanationOfBenefit.requestOrganization ExplanationOfBenefit.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

Structure

0..1 Type Finer grained Period Creation Insurer Responsible organization Reference ( ReferralRequest ) Treatment Referral 0..1 Reference Claim reference 0..1 Reference complete | error | partial Disposition Message Related file Type of party: Subscriber, Provider, other organization | patient | practitioner | relatedperson BackboneElement positiveInt CodeableConcept Type Reason associated with the information Billing practitioner Claim Care Team Role Codes Type, classification or Specialization Package billing code Procedures Goods and Services Type of service or product Billing Code Service/Product Service List of Adjudication category such as co-pay, eligible, benefit, etc. Type of service or product Billing Code List of Billing Code Net additional List of Type of service Billing Code List of Added Type of service Billing Code List of Total Cost Identifier of display | print | printoper CodeableConcept Detailed services covered within the type Deductable, visits, benefit amount
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . ExplanationOfBenefit N 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 Σ Number for tracking

. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus Binding: Explanation Of Benefit Status ( Required )
. . type . statusReason Σ 0..1 string Reason for status change
... type Σ 1..1 CodeableConcept Category or discipline
Example Binding: Claim Type Codes ( Required Extensible )
. . . subType 0..* 0..1 CodeableConcept More granular claim type information
Binding: Example Claim SubType Codes ( Example )
. . patient . use Σ 0..1 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
... subject Σ 1..1 Reference ( Patient | Group ) The subject recipient(s) of the Products products and Services services
. . . billablePeriod Σ 0..1 Period Relevant time frame for charge submission the claim
. . . created Σ 0..1 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 the EOB reimbursement
. . . provider Σ 0..1 Reference ( Practitioner ) Responsible provider for the claim organization 0..1 Reference | PractitionerRole ( | Organization ) Party responsible for the claim
. . referral . priority 0..1 0..1 facility CodeableConcept Desired processing urgency
Binding: Process Priority Codes ( Location Preferred )
Servicing Facility
. . claim . fundsReserveRequested 0..1 Reference ( Claim ) 0..1 claimResponse CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes ( ClaimResponse Preferred )
Claim response reference
. . . outcome fundsReserve 0..1 CodeableConcept Funds reserved status
Claim Processing Binding: Funds Reservation Codes ( Example Preferred ) disposition 0..1 string
. . . related 0..* BackboneElement Prior or corollary claims
Related Claims which may be revelant to processing this claim
. . . . 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..1 0..* BackboneElement Event information

Party to be paid any benefits payable
. . . . type 0..1 1..1 CodeableConcept Specific event
Claim Payee Binding: Dates Type Codes ( Example )
. . . . when[x] 1..1 Occurance date or period
. . . . resourceType . whenDateTime dateTime
. . . . . whenPeriod Period
. . . payee 0..1 BackboneElement Recipient of benefits payable
.... type 0..1 CodeableConcept Category of recipient
PayeeResourceType Binding: Claim Payee Type Codes ( Required Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
Party to receive the payable
. . information . referral 0..1 0..* Reference ( ServiceRequest ) Treatment Referral
. . . encounter Exceptions, special considerations, 0..* Reference ( Encounter ) Encounters associated with the condition, situation, prior or concurrent issues listed treatments

. . sequence . facility 0..1 1..1 Reference ( Location | Organization ) Servicing Facility
. . . claim 0..1 Reference ( Claim ) Claim reference
Information instance identifier
. . category . claimResponse 0..1 1..1 Reference ( ClaimResponse ) Claim response reference
. . . outcome General class of information Σ 1..1 code queued | complete | error | partial
Binding: Claim Information Category Processing Codes ( Example Required )
. . code . decision Σ 0..1 CodeableConcept Result of information the adjudication
Exception Binding: Claim Adjudication Decision Codes ( Example Preferred )
. . timing[x] . disposition 0..1 string Disposition Message
When it occurred
. . timingDate . preAuthRef 0..* date string Preauthorization reference

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

. . value[x] . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
Additional Data or supporting information
. . . careTeam valueString 0..* string BackboneElement Care Team members

. . . valueQuantity . sequence 1..1 Quantity positiveInt Order of care team
. . . valueAttachment . provider 1..1 Attachment Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . role valueReference 0..1 CodeableConcept Reference Function within the team
Binding: Claim Care Team Role Codes ( Any Preferred )
. . . . reason specialty 0..1 Coding CodeableConcept Practitioner or provider specialization
Missing Tooth Reason Binding: Example Provider Qualification Codes ( Example )
. . careTeam . supportingInfo 0..* BackboneElement Supporting information
Care Team members
. . . . sequence 1..1 positiveInt Information instance identifier
Number to covey order of careteam
. . . provider . category 1..1 CodeableConcept Reference Classification of the supplied information
Binding: Claim Information Category Codes ( Practitioner | Organization Preferred )
Member of the Care Team
. . . responsible . code 0..1 CodeableConcept boolean Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . role . timingDateTime dateTime
. . . . . timingPeriod Period
. . . . . timingTiming 0..1 CodeableConcept Timing Role on the team
. . . . value[x] ( Example ) 0..1 * Data to be provided
. . . . qualification reason 0..1 CodeableConcept Coding Explanation for the information
Example Provider Qualification Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information
List of Diagnosis
. . . . sequence 1..1 positiveInt Diagnosis instance identifier
Number to covey order of diagnosis
. . . . diagnosis[x] 1..1 Patient's diagnosis 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 )

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

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

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Patient's list of procedures performed 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..1 0..* BackboneElement Patient insurance information

Insurance or medical plan
. . . coverage . focal Σ 0..1 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . preAuthRef 0..* string Prior authorization reference number
Pre-Authorization/Determination Reference
. . . accident 0..1 BackboneElement Details of an accident the event
. . . . date 0..1 date When the accident incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon ( Required Extensible )
. . . . location[x] 0..1 Where the event occurred
Accident Place
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . employmentImpacted . patientPaid 0..1 Period Money Paid by the patient
Period unable to work
. . hospitalization . item 0..1 0..* Period BackboneElement Product or service provided

Period in hospital
. . . item . sequence 0..* 1..1 BackboneElement positiveInt Item instance identifier
. . . . sequence careTeamSequence 1..1 0..* positiveInt Applicable care team members

Service instance
. . . careTeamLinkId . diagnosisSequence 0..* positiveInt Applicable careteam members diagnoses

. . . . diagnosisLinkId procedureSequence 0..* positiveInt Applicable diagnoses procedures

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

. . . informationLinkId . traceNumber 0..* Identifier positiveInt Number for tracking

.... subject Applicable exception 0..1 Reference ( Patient | Group ) The recipient of the products and supporting information services
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory Category Codes ( Example )
. . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of Service 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 )
. . . . quantity patientPaid 0..1 Money Paid by the patient
.... quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . factor 0..1 decimal Price scaling factor
. . . . net tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier

. . . . bodySite 0..* BackboneElement 0..1 Anatomical location

CodeableConcept
. . . . . site Service 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 which apply

. . . . 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 adjudication outcome
Binding: Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . . quantity 0..1 Quantity Non-monitary value
. . . . . value decisionDate 0..1 decimal dateTime When was adjudication performed
Non-monitory value
. . . . detail 0..* BackboneElement Additional items

. . . . . sequence 1..1 positiveInt Product or service provided
Service instance
. . . . type . traceNumber 1..1 0..* CodeableConcept Identifier Number for tracking
Group or type of product or service
ActInvoiceGroupCode ( Required )
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory Category Codes ( Example )
. . . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

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

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

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

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

. . . . . . sequence 1..1 positiveInt Product or service provided
Service instance
. . . . . . type traceNumber 1..1 0..* CodeableConcept Identifier Number for tracking
Type of product or service
ActInvoiceGroupCode ( Required )
. . . . . . 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 )
Type of service
. . . . . . productOrService 0..1 CodeableConcept Billing, service, product, or product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . . . service 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 specific reason for item inclusion the product or service is provided under
Binding: Example Program Reason Codes ( Example )

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

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

. . . . . . reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details
Language if different from the resource
. . . addItem 0..* BackboneElement Insurer added line items

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

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

.... subDetailSequence 0..* positiveInt Subdetail sequence number
Service instances
. . . revenue . 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

.... 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 product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . service 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 )

. . . fee . 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
Professional fee
. . . . quantity 0..1 SimpleQuantity Count of products or Product services
.... unitPrice 0..1 Money Fee, charge or cost per item
. . . . noteNumber factor 0..1 decimal Price scaling factor
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... 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 which apply

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

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

. . . . . revenue traceNumber 0..* Identifier 0..1 Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category productOrService 0..1 CodeableConcept Billing, service, product, or product drug code
Benefit SubCategory Binding: USCLS Codes ( Example )
. . . . service . 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 )

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

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

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

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

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

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

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

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

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

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

.... class Processing notes 0..1 CodeableConcept Business kind of note
Binding: ProcessNoteClass ( Example )
. . . . number 0..1 positiveInt Note instance identifier
Sequence number for this note
. . . . type 0..1 CodeableConcept Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 0..1 string markdown Note explanitory explanatory text
. . . . language 0..1 CodeableConcept Language if different from of the resource text
Common Languages ( Extensible but limited to Binding: All Languages ( Required ) benefitBalance Balance by Benefit Category
Additional Bindings Purpose
Common Languages 0..* BackboneElement Starter

. . . category benefitPeriod 0..1 Period When the benefits are applicable
1..1
. . . benefitBalance Type of services covered 0..* BackboneElement Balance by Benefit Category Codes ( Example )

. . . . subCategory category 0..1 1..1 CodeableConcept Benefit classification
Binding: Benefit SubCategory 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 ) The EOB Business Identifier 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 [0..1] [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, eg, e.g. oral, pharmacy, vision, insitutional, institutional, professional type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim (Strength=Required) null (Strength=Extensible) Example Claim Type ! ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granulat claim typecode null (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Patient Resource A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the 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 under the identified policy and report back what the Benefit payable would be had the services actually been provided patient use : code [1..1] « null (Strength=Required) Use ! » The 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 subject : Reference [0..1] [1..1] « Patient | Group » The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the EOB this resource was created created : dateTime [0..1] [1..1] The person Individual who created the explanation of benefit claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The insurer which is party responsible for the explanation of benefit authorization, adjudication and reimbursement insurer : Reference [0..1] « Organization » The provider which is responsible for the claim claim, predetermination or preauthorization provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The provider provider-required urgency of processing the request. Typical values include: stat, normal deferred priority : CodeableConcept [0..1] « null (Strength=Preferred) ProcessPriorityCodes ? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserveRequested : CodeableConcept [0..1] « null (Strength=Preferred) 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] « null (Strength=Preferred) FundsReservationCodes ? » Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is responsible 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 claim dispensing of pharmacy services, medications or products organization originalPrescription : Reference [0..1] Organization « DeviceRequest | MedicationRequest | ServiceRequest | VisionPrescription » The referral resource which lists information received by the date, practitioner, reason and other claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] ReferralRequest « 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: invoice number, instance of the adjudication request: claim number, pre-determination predetermination or pre-authorization number preauthorization claim : Reference [0..1] « Claim » The business identifier for the instance: invoice number, claim number, pre-determination instance of the adjudication response: claim, predetermination or pre-authorization number preauthorization response claimResponse : Reference [0..1] « ClaimResponse » Processing The outcome errror, partial of the claim, predetermination, or complete preauthorization processing outcome : CodeableConcept code [0..1] [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing (Strength=Example) claim, predetermination, or preauthorization adjudication Claim Processing decision ?? : CodeableConcept [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A human readable description of the status of the adjudication disposition : string [0..1] Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference [0..1] MedicationRequest | VisionPrescription Original prescription which has been superceded by this prescription to support from the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication Insurer which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication used in later communications which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' originalPrescription : Reference [0..1] MedicationRequest Precedence (primary, secondary, etc.) refers to this adjudication precedence preAuthRef : positiveInt string [0..1] [0..*] The start and optional end dates of when timeframe during which the patient was precluded from working due supplied preauthorization reference may be quoted on claims to obtain the treatable condition(s) adjudication as provided employmentImpacted preAuthRefPeriod : Period [0..1] [0..*] The start A package billing code or bundle code used to group products and optional end dates of when the patient was confined services to a treatment center particular health condition (such as heart attack) which is based on a predetermined grouping code system hospitalization diagnosisRelatedGroup : Period CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » The total cost This indicates the relative order of a series of EOBs related to different coverages for the same suite of services reported totalCost precedence : Money positiveInt [0..1] The amount of deductable applied which was not allocated paid by the patient, in total at the claim claim level or specifically for the item and detail level, to any particular service line the provider for goods and services unallocDeductable patientPaid : Money [0..1] Total amount of benefit payable (Equal to sum of A code for the Benefit amounts from all detail lines and additions less form to be used for printing the Unallocated Deductable) content totalBenefit formCode : Money CodeableConcept [0..1] « null (Strength=Example) FormCodes ?? » The form to be used actual form, by reference or inclusion, for printing the content or an EOB form : CodeableConcept Attachment [0..1] The forms codes. (Strength=Example) term of the benefits documented in this response Form benefitPeriod ?? : Period [0..1] RelatedClaim Other claims which are related Reference to this claim such a related Claim or ExplanationOfBenefit as prior a representation of a claim versions or for related services claim : Reference [0..1] « Claim | ExplanationOfBenefit » For example prior or umbrella A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim null (Strength=Example) Example Related Claim Relatio... ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # 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 | patient | practitioner | relatedperson to whom any payment will be made resourceType party : CodeableConcept Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam The type of payee Resource (Strength=Required) A number to uniquely identify care team entries PayeeResourceType ! sequence : positiveInt [1..1] Party to be reimbursed: Subscriber, provider, other Member of the team who provided the product or service party provider : Reference [0..1] [1..1] « Practitioner | Organization PractitionerRole | Patient Organization | » RelatedPerson The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « null (Strength=Preferred) ClaimCareTeamRoleCodes ? » The specialization of the practitioner or provider which is applicable for this service specialty : CodeableConcept [0..1] « null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation Sequence of the information element which serves A number to provide a link 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) Claim Information Category ClaimInformationCategoryCodes ?? ? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) Exception 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] string | Quantity | Attachment | Reference ( Any ) For example, provides Provides the reason for: in the additional stay, or missing tooth or any other 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) Missing Tooth Reason MissingToothReasonCodes ?? » CareTeam Diagnosis Sequence of careteam which serves A number to order and provide a link uniquely identify diagnosis entries sequence : positiveInt [1..1] The members nature of the team who provided the overall service provider : Reference [1..1] Practitioner | Organization The practitioner who is billing and responsible for the claimed services rendered to the patient responsible : boolean [0..1] The lead, assisting illness or supervising practitioner and their discipline if problem in a multidisiplinary team role : CodeableConcept [0..1] The role codes for the care team members. (Strength=Example) Claim Care Team Role ?? The qualification which is applicable for this service qualification : CodeableConcept [0..1] Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? Diagnosis Sequence of diagnosis which serves to provide coded form or as a link sequence : positiveInt [1..1] The diagnosis reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes null (Strength=Example) ICD-10 ICD10Codes ?? » The type of When the Diagnosis, for example: admitting, primary, secondary, discharge condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example) null (Strength=Preferred) Example Diagnosis Type ExampleDiagnosisTypeCodes ?? ? » The package billing code, for example DRG, based on Indication of whether the assigned grouping code system diagnosis was present on admission to a facility packageCode onAdmission : CodeableConcept [0..1] « The DRG codes associated with the diagnosis (Strength=Example) null (Strength=Preferred) Example Diagnosis Related Gro... ExampleDiagnosisOnAdmissionCo... ?? ? » Procedure Sequence of procedures which serves A number to order and provide a link uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « null (Strength=Preferred) ExampleProcedureTypeCodes ? » Date and optionally time the procedure was performed date : dateTime [0..1] The procedure 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-10 Procedure 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 program or plan identification, underwriter or payor 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 [0..1] [1..1] « Coverage » A list of references from Reference numbers previously provided by the Insurer insurer to which these the provider to be quoted on subsequent claims containing services pertain or products related to the prior authorization preAuthRef : string [0..*] Accident Date of an accident which these event related to the products and services are addressing contained in the claim date : date [0..1] Type The type or context of accident: work, auto, etc 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. (Strength=Required) null (Strength=Extensible) ActIncidentCode ! + » Where The physical location of the accident occurred event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A service line number to uniquely identify item entries sequence : positiveInt [1..1] Careteam applicable for Care team members related to this service or product line careTeamLinkId careTeamSequence : positiveInt [0..*] Diagnosis Diagnoses applicable for this service or product line diagnosisLinkId diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product line procedureLinkId procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable applicable for this service or product line informationLinkId 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 reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the type item. This element may be the start of thing being grouped eg. 'glasses' a range of .productOrService codes used in conjunction with .productOrServiceEnd or 'compound' it may be a solo element where .productOrServiceEnd is not used service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier 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 type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The date or dates when the enclosed suite of services were 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) Example Service Place 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 node group then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: unit Quantity * group (if a grouper) or the line item. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of 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) etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch null (Strength=Example) Oral Site OralSiteCodes ?? » A region or surface of the site, eg. bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations null (Strength=Example) Surface 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..*] Encounter [0..1] « null (Strength=Preferred) ClaimAdjudicationDecisionsCod... ? » A list The reasons for the result of note references to the notes provided below claim, predetermination, or preauthorization adjudication noteNumber reason : positiveInt CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Adjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) null (Strength=Preferred) Adjudication Value AdjudicationValueCodes ?? ? » Adjudication reason such as limit reached 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) Adjudication Reason AdjudicationReasonCodes ?? » Monitory Monetary amount associated with the code category amount : Money [0..1] A non-monetary value for example a percentage. 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 service line number claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] The type of product Trace number for tracking purposes. May be defined at the jurisdiction level or service between trading partners type traceNumber : CodeableConcept Identifier [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! [0..*] The type of reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the type item. This element may be the start of thing being grouped eg. 'glasses' a range of .productOrService codes used in conjunction with .productOrServiceEnd or 'compound' it may be a solo element where .productOrServiceEnd is not used service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier productOrServiceEnd : CodeableConcept [0..*] [0..1] « null (Strength=Example) USCLSCodes ?? » Item type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason 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 node group then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: unit Quantity * group (if a grouper) or the line item.detail. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A service line number claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items sequence : positiveInt [1..1] The type of product Trace number for tracking purposes. May be defined at the jurisdiction level or service between trading partners type traceNumber : CodeableConcept Identifier [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! [0..*] The type of reveneu 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) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » A When the value is a group code to indicate then this item collects a set of related item details, otherwise this contains the Professional Service product, service, drug or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) other billing code for the 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 service productOrService : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification This contains the end of a range of product, service, drug or modifiers codes, eg other billing codes for Oral whether the treatment item. This element is cosmetic or associated with TMJ, or for medical whether not used when the treatment was outside .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the clinic or out start of office hours the range. Typically this value may be used only with preauthorizations and not with claims modifier productOrServiceEnd : CodeableConcept [0..*] [0..1] « null (Strength=Example) USCLSCodes ?? » Item type typification or modifiers codes, eg codes to convey additional context for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes null (Strength=Example) Example Program Reason 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] The If the item is not a group then this is the fee for an addittional service or the product or charge 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 addittional service or this product or charge. For example, service tax : Money [0..1] The total amount claimed for the formula: line item.detail.subDetail. Net = unit Quantity price * unit Price (Cost per Point) quantity * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem List of input service Claim items which this service line is intended to replace sequenceLinkId itemSequence : positiveInt [0..*] The type sequence number of reveneu 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 cost center providing between trading partners traceNumber : Identifier [0..*] The party to whom the product professional services and/or service products have been supplied or are being considered and for whom actual for facast reimbursement is sought revenue subject : CodeableConcept Reference [0..1] « Patient | Group » Codes 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 centers supplying center providing the service product and/or products. service revenue : CodeableConcept [0..1] « null (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, group code then use this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code to indicate for the Professional Service item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If it may be a grouping item then use solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [0..1] « 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 indicate convey the type start of thing being grouped eg. 'glasses' or 'compound' the range. Typically this value may be used only with preauthorizations and not with claims service productOrServiceEnd : CodeableConcept [0..1] « Allowable service and product codes null (Strength=Example) USCLS USCLSCodes ?? » Item typification Request or modifiers codes, eg Referral for Oral whether the treatment is cosmetic Goods or associated with TMJ, Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « null (Strength=Example) ModifierTypeCodes ?? » Item type or modifiers codes, eg for Oral whether Identifies the treatment is cosmetic program under which this may be recovered programCode : CodeableConcept [0..*] « null (Strength=Example) ExampleProgramReasonCodes ?? » The date or associated with TMJ, dates when the service or an appliance product was lost supplied, performed or stolen. completed serviced[x] : DataType [0..1] « date | Period » Where the product or service was provided location[x] : DataType [0..1] « CodeableConcept | Address | Reference ( Location ); null (Strength=Example) Modifier type ExampleServicePlaceCodes ?? » The fee charged amount paid by the patient, in total at the claim claim level or specifically for the professional 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 list real number that represents a multiplier used in determining the overall value of note references 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 total of taxes applicable for this product or 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 provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemsDetail AddedItemBodySite Physical service site on the patient (limb, tooth, etc.) site : CodeableReference [1..*] « BodyStructure ; null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « null (Strength=Example) SurfaceCodes ?? » AddedItemDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » Codes for When the revenue value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or cost centers supplying other billing code for the service and/or products. 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 [0..1] « null (Strength=Example) Example Revenue Center USCLSCodes ?? » Health Care Service Type Codes to identify This contains the classification end of service a range of product, service, drug or benefits 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 not with claims category productOrServiceEnd : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory USCLSCodes ?? » A code Item typification or modifiers codes to indicate convey additional context for the Professional Service product or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service modifier : CodeableConcept [0..*] « 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] Allowable The number of repetitions of a service and or product codes (Strength=Example) USCLS quantity ?? : Quantity ( SimpleQuantity ) [0..1] Item typification or modifiers codes, eg If the item is not a group then this is the fee for Oral whether the treatment product or service, otherwise this is cosmetic 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 associated with TMJ, surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The total of taxes applicable for this product or service tax : Money [0..1] The total amount claimed for medical whether the treatment was outside the clinic group (if a grouper) or out the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of office hours this item modifier noteNumber : CodeableConcept positiveInt [0..*] AddedItemDetailSubDetail Item Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or modifiers codes, eg 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 item details, otherwise this contains the product, service, drug or other billing code for Oral whether the treatment 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 cosmetic not used productOrService : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or associated 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 TMJ, preauthorizations and not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or an appliance was lost modifiers codes to convey additional context for the product or stolen. service modifier : CodeableConcept [0..*] « null (Strength=Example) Modifier type ModifierTypeCodes ?? » The fee charged amount paid by the patient, in total at the claim claim level or specifically for the professional 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 list real number that represents a multiplier used in determining the overall value of note references 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 total of taxes applicable for this product or 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 provided 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] « 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 claim benefits payable type : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example) null (Strength=Preferred) Example Payment Type ExamplePaymentTypeCodes ?? ? » Adjustment Total amount of all adjustments to the this payment of included in this transaction which is are not related to adjudication of this transaction 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) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? ? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Payable Benefits payable less any payment adjustment amount : Money [0..1] Payment identifer Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note An integer associated with each A code to indicate the business purpose of the note which may be referred class : CodeableConcept [0..1] « null (Strength=Example) ProcessNoteClass?? » A number to from each service line item uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note purpose: Print/Display text type : CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The note text explanation or description associated with the processing text : string markdown [0..1] The ISO-639-1 alpha 2 A code in lower case for to define the language, optionally followed by a hyphen and language used in the ISO-3166-1 alpha 2 code for text of the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English note language : CodeableConcept [0..1] « A human language. (Strength=Extensible) null (Strength=Required) Common Languages + AllLanguages ! » BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc 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 etc. (Strength=Example) Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses null (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » True if the indicated class of service is excluded from the plan, missing or False indicated indicates the product or service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit, for example MED01, or DENT2 benefit name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' benefit or services covered description : string [0..1] Network designation 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) Network Type NetworkTypeCodes ?? » Unit designation: 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) Unit Type UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime null (Strength=Example) Benefit Term BenefitTermCodes ?? » Benefit Deductable, visits, Classification of benefit amount being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. null (Strength=Example) Benefit Type BenefitTypeCodes ?? » Benefits allowed The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » Benefits used 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 claim versions 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. Often there are mutiple jurisdiction specific valuesets which are required issues information supportingInfo [0..*] The members of Information about diagnoses relevant to the team who provided claim items diagnosis [0..*] Procedures performed on the overall service as well as their role and whether responsible patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and qualifications services specified on the claim careTeam insurance [0..*] Ordered list Details of patient diagnosis for a accident which care resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is sought performed or applies diagnosis bodySite [0..*] Ordered list The high-level results of patient procedures performed to support the adjudication if adjudication has been performed procedure reviewOutcome [0..*] [0..1] Financial instrument by which payment information for health care 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 insurance adjudication [0..1] [0..*] An accident which resulted in The high-level results of the need for healthcare services adjudication if adjudication has been performed accident reviewOutcome [0..1] The adjudications adjudication results adjudication [0..*] The adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..*] [0..1] The adjudications adjudication results adjudication [0..*] Third tier Third-tier of goods and services subDetail [0..*] Second tier Second-tier of goods and services detail [0..*] First tier A claim line. Either a simple (a product or service) or a 'group' of goods and services 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 adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The adjudications high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] The second tier 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 detail subDetail [0..*] The first tier second-tier service adjudications for payor payer added services detail [0..*] The first-tier service adjudications for 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 claim if adjudication of the claim has been paid payment [0..1] Note text 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>
 <
 <</type>
 <</subType>
 <</patient>
 <</billablePeriod>
 <
 <</enterer>
 <</insurer>
 <</provider>
 <</organization>
 <</referral>
 <</facility>
 <</claim>
 <</claimResponse>
 <</outcome>
 <
 <
  <</claim>
  <</relationship>
  <</reference>

 <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>
 <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><!-- 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><!-- 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>
 <
  <</type>
  <</resourceType>
  <</party>

 <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><!-- 0..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <
  <
  <</category>
  <</code>
  <</timing[x]>
  <</value[x]>
  <</reason>
 </information>
 <
  <
  <</provider>
  <
  <</role>
  <</qualification>

 <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><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <
  <
  <</diagnosis[x]>
  <</type>
  <</packageCode>

 <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]><!-- 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>

 </diagnosis>
 <
  <
  <
  <</procedure[x]>

 <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>
 <
 <
  <</coverage>
  <

 <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>
 <
  <
  <</type>
  <</location[x]>

 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 0..1 When the incident occurred -->
  <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>
 <</employmentImpacted>
 <</hospitalization>
 <
  <
  <
  <
  <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</programCode>
  <</serviced[x]>
  <</location[x]>
  <</quantity>
  <</unitPrice>
  <
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</encounter>
  <
  <
   <</category>
   <</reason>
   <</amount>
   <

 <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><!-- 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 -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <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>
  <
   <
   <</type>
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</programCode>
   <</quantity>
   <</unitPrice>
   <
   <</net>
   <</udi>
   <
   <</adjudication>
   <
    <
    <</type>
    <</revenue>
    <</category>
    <</service>
    <</modifier>
    <</programCode>
    <</quantity>
    <</unitPrice>
    <
    <</net>
    <</udi>
    <
    <</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><!-- 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 -->
   <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><!-- 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 -->
    <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>
 <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</fee>
  <
  <</adjudication>
  <
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</fee>
   <
   <</adjudication>

 <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 -->
  <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 -->
  <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>
  <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 -->
   <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>
   <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 -->
    <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>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <
  <</type>
  <</adjustment>
  <</adjustmentReason>
  <
  <</amount>
  <</identifier>

 <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>
 <</form>
 <
  <
  <</type>
  <
  <</language>

 <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 -->
  <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>
  <</subCategory>
  <
  <
  <
  <</network>
  <</unit>
  <</term>

  <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>
   <</allowed[x]>
   <</used[x]>

   <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" : "",

  "resourceType" : "ExplanationOfBenefit",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
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  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "

  "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) }

  },
  "
  "
  "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    
    ">",
    " },
    
    " },
    " },
    " },
    "
    "
    "
    "
    "
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    "
    "
    "
    "
      "
      "
      "
      "

  "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

      }]
    }]
  }],
  "
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      "
      "

  "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:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 4
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
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  ], ...;
  fhir:
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    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
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  ], ...;
  fhir:
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    # . One of these 2
      fhir: ]
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  ], ...;
  fhir:
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  ];
  fhir:
    fhir:
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    # . One of these 2
      fhir: ]
      fhir:) ]
  ];
  fhir:
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    # . One of these 2
      fhir: ]
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    # . One of these 3
      fhir: ]
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      fhir:) ]
    fhir:
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    ], ...;
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      ], ...;
    ], ...;
  ], ...;
  fhir:
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    ], ...;
  ], ...;
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  ];
  fhir:
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  ], ...;
  fhir:
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    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 DSTU2 from both R4 and R4B

ExplanationOfBenefit.status Added Element ExplanationOfBenefit.type
ExplanationOfBenefit Added Element
ExplanationOfBenefit.subType ExplanationOfBenefit.traceNumber
  • Added Element
ExplanationOfBenefit.patient ExplanationOfBenefit.statusReason
  • Added Element
ExplanationOfBenefit.billablePeriod ExplanationOfBenefit.subject
  • Added Mandatory Element
ExplanationOfBenefit.enterer
  • Type Reference: Added Element Target Types Patient, RelatedPerson
ExplanationOfBenefit.insurer
  • Added Element ExplanationOfBenefit.provider Added Element ExplanationOfBenefit.referral Added Element ExplanationOfBenefit.facility Added Element ExplanationOfBenefit.claim Added Element ExplanationOfBenefit.claimResponse Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.outcome ExplanationOfBenefit.provider
  • Type Min Cardinality changed from code 1 to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) ExplanationOfBenefit.related Added Element 0
ExplanationOfBenefit.related.claim
  • Type Reference: Added Element ExplanationOfBenefit.related.relationship Added Element ExplanationOfBenefit.related.reference Added Element Target Type ExplanationOfBenefit
ExplanationOfBenefit.prescription
  • Type Reference: Added Element Target Types DeviceRequest, ServiceRequest
ExplanationOfBenefit.originalPrescription
  • Type Reference: Added Element ExplanationOfBenefit.payee Added Element ExplanationOfBenefit.payee.type Added Element ExplanationOfBenefit.payee.resourceType Added Element ExplanationOfBenefit.payee.party Added Element ExplanationOfBenefit.information Added Element ExplanationOfBenefit.information.sequence Added Element ExplanationOfBenefit.information.category Added Element ExplanationOfBenefit.information.code Added Element ExplanationOfBenefit.information.timing[x] Added Element ExplanationOfBenefit.information.value[x] Added Element ExplanationOfBenefit.information.reason Added Element ExplanationOfBenefit.careTeam Added Element ExplanationOfBenefit.careTeam.sequence Added Element ExplanationOfBenefit.careTeam.provider Added Element ExplanationOfBenefit.careTeam.responsible Added Element Target Types DeviceRequest, ServiceRequest, VisionPrescription
ExplanationOfBenefit.careTeam.role ExplanationOfBenefit.event
  • Added Element
ExplanationOfBenefit.careTeam.qualification ExplanationOfBenefit.event.type
  • Added Mandatory Element
ExplanationOfBenefit.diagnosis ExplanationOfBenefit.event.when[x]
  • Added Mandatory Element
ExplanationOfBenefit.diagnosis.sequence ExplanationOfBenefit.encounter
  • Added Element
ExplanationOfBenefit.diagnosis.diagnosis[x] ExplanationOfBenefit.facility
  • Type Reference: Added Element Target Type Organization
ExplanationOfBenefit.diagnosis.type ExplanationOfBenefit.outcome
ExplanationOfBenefit.diagnosis.packageCode ExplanationOfBenefit.decision
  • Added Element
ExplanationOfBenefit.procedure ExplanationOfBenefit.diagnosisRelatedGroup
  • Added Element
ExplanationOfBenefit.procedure.sequence ExplanationOfBenefit.careTeam.specialty
  • Added Element
ExplanationOfBenefit.procedure.date ExplanationOfBenefit.supportingInfo.timing[x]
  • Added Element Add Types dateTime, Timing
    • ExplanationOfBenefit.procedure.procedure[x]
  • Added Element Remove Type date
ExplanationOfBenefit.precedence ExplanationOfBenefit.supportingInfo.value[x]
  • Added Element 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.insurance
  • Added Element ExplanationOfBenefit.insurance.coverage Added Element ExplanationOfBenefit.insurance.preAuthRef Added Element ExplanationOfBenefit.accident Added Element ExplanationOfBenefit.accident.date Added Element ExplanationOfBenefit.accident.type Added Element ExplanationOfBenefit.accident.location[x] Added Element ExplanationOfBenefit.employmentImpacted Added Element ExplanationOfBenefit.hospitalization Added Element ExplanationOfBenefit.item Added Element ExplanationOfBenefit.item.sequence Added Element ExplanationOfBenefit.item.careTeamLinkId Added Element ExplanationOfBenefit.item.diagnosisLinkId Added Element ExplanationOfBenefit.item.procedureLinkId Added Element ExplanationOfBenefit.item.informationLinkId Added Element ExplanationOfBenefit.item.revenue Added Element ExplanationOfBenefit.item.category Added Element ExplanationOfBenefit.item.service Added Element ExplanationOfBenefit.item.modifier Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.programCode ExplanationOfBenefit.patientPaid
  • Added Element
ExplanationOfBenefit.item.serviced[x] ExplanationOfBenefit.item.traceNumber
  • Added Element
ExplanationOfBenefit.item.location[x] ExplanationOfBenefit.item.subject
  • Added Element
ExplanationOfBenefit.item.quantity ExplanationOfBenefit.item.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.unitPrice ExplanationOfBenefit.item.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.factor ExplanationOfBenefit.item.request
  • Added Element
ExplanationOfBenefit.item.net ExplanationOfBenefit.item.patientPaid
  • Added Element
ExplanationOfBenefit.item.udi ExplanationOfBenefit.item.tax
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Added Element ExplanationOfBenefit.item.subSite Added Element ExplanationOfBenefit.item.encounter Added Element ExplanationOfBenefit.item.noteNumber Added Element ExplanationOfBenefit.item.adjudication Added Element ExplanationOfBenefit.item.adjudication.category Added Element ExplanationOfBenefit.item.adjudication.reason Added Element ExplanationOfBenefit.item.adjudication.amount Added Element ExplanationOfBenefit.item.adjudication.value Added Element ExplanationOfBenefit.item.detail Added Element ExplanationOfBenefit.item.detail.sequence Added Element ExplanationOfBenefit.item.detail.type Added Element ExplanationOfBenefit.item.detail.revenue Added Element ExplanationOfBenefit.item.detail.category Added Element ExplanationOfBenefit.item.detail.service Added Element ExplanationOfBenefit.item.detail.modifier Added Element Max Cardinality changed from 1 to *
    • ExplanationOfBenefit.item.detail.programCode
  • Added Element Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.item.detail.quantity ExplanationOfBenefit.item.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.item.detail.unitPrice ExplanationOfBenefit.item.bodySite.subSite
  • Added Element
ExplanationOfBenefit.item.detail.factor ExplanationOfBenefit.item.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.net ExplanationOfBenefit.item.reviewOutcome.decision
  • Added Element
ExplanationOfBenefit.item.detail.udi ExplanationOfBenefit.item.reviewOutcome.reason
  • Added Element
ExplanationOfBenefit.item.detail.noteNumber ExplanationOfBenefit.item.reviewOutcome.preAuthRef
  • Added Element
ExplanationOfBenefit.item.detail.adjudication ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod
  • Added Element
ExplanationOfBenefit.item.detail.subDetail ExplanationOfBenefit.item.adjudication.quantity
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.sequence ExplanationOfBenefit.item.adjudication.decisionDate
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.type ExplanationOfBenefit.item.detail.traceNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.revenue ExplanationOfBenefit.item.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.category ExplanationOfBenefit.item.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.service ExplanationOfBenefit.item.detail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.modifier ExplanationOfBenefit.item.detail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.programCode ExplanationOfBenefit.item.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.quantity ExplanationOfBenefit.item.detail.subDetail.traceNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.unitPrice ExplanationOfBenefit.item.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.item.detail.subDetail.factor ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.net ExplanationOfBenefit.item.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.udi ExplanationOfBenefit.item.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.noteNumber ExplanationOfBenefit.item.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.adjudication ExplanationOfBenefit.addItem.traceNumber
  • Added Element
ExplanationOfBenefit.addItem ExplanationOfBenefit.addItem.subject
  • Added Element
ExplanationOfBenefit.addItem.sequenceLinkId ExplanationOfBenefit.addItem.informationSequence
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.service ExplanationOfBenefit.addItem.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.addItem.modifier ExplanationOfBenefit.addItem.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.addItem.fee ExplanationOfBenefit.addItem.request
  • Added Element
ExplanationOfBenefit.addItem.noteNumber ExplanationOfBenefit.addItem.patientPaid
  • Added Element
ExplanationOfBenefit.addItem.adjudication ExplanationOfBenefit.addItem.tax
  • Added Element
ExplanationOfBenefit.addItem.detail ExplanationOfBenefit.addItem.bodySite
  • Added Element Max Cardinality changed from 1 to *
    • ExplanationOfBenefit.addItem.detail.revenue
  • Added Element Type changed from CodeableConcept to BackboneElement
ExplanationOfBenefit.addItem.detail.category ExplanationOfBenefit.addItem.bodySite.site
  • Added Mandatory Element
ExplanationOfBenefit.addItem.detail.service ExplanationOfBenefit.addItem.bodySite.subSite
  • Added Element
ExplanationOfBenefit.addItem.detail.modifier ExplanationOfBenefit.addItem.reviewOutcome
  • Added Element
ExplanationOfBenefit.addItem.detail.fee ExplanationOfBenefit.addItem.detail.traceNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.noteNumber ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.adjudication ExplanationOfBenefit.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.totalCost ExplanationOfBenefit.addItem.detail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.unallocDeductable ExplanationOfBenefit.addItem.detail.patientPaid
  • Added Element
ExplanationOfBenefit.totalBenefit ExplanationOfBenefit.addItem.detail.tax
  • Added Element
ExplanationOfBenefit.payment ExplanationOfBenefit.addItem.detail.reviewOutcome
  • Added Element
ExplanationOfBenefit.payment.type ExplanationOfBenefit.addItem.detail.subDetail.traceNumber
  • Added Element
ExplanationOfBenefit.payment.adjustment ExplanationOfBenefit.addItem.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.payment.adjustmentReason ExplanationOfBenefit.addItem.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ExplanationOfBenefit.payment.date ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ExplanationOfBenefit.payment.amount ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
  • Added Element
ExplanationOfBenefit.payment.identifier ExplanationOfBenefit.addItem.detail.subDetail.tax
  • Added Element
ExplanationOfBenefit.form ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome
  • Added Element
ExplanationOfBenefit.processNote ExplanationOfBenefit.processNote.class
  • Added Element
ExplanationOfBenefit.processNote.number ExplanationOfBenefit.processNote.type
  • Added Element Type changed from code to CodeableConcept
    • ExplanationOfBenefit.processNote.type
  • Added Element Change binding strength from required to extensible
ExplanationOfBenefit.processNote.text
  • Added Element Type changed from string to markdown
ExplanationOfBenefit.processNote.language
  • Added Element ExplanationOfBenefit.benefitBalance Added Element ExplanationOfBenefit.benefitBalance.category Added Element ExplanationOfBenefit.benefitBalance.subCategory Added Element ExplanationOfBenefit.benefitBalance.excluded Added Element ExplanationOfBenefit.benefitBalance.name Added Element ExplanationOfBenefit.benefitBalance.description Added Element ExplanationOfBenefit.benefitBalance.network Added Element ExplanationOfBenefit.benefitBalance.unit Added Element ExplanationOfBenefit.benefitBalance.term Added Element Change binding strength from preferred to required
    • ExplanationOfBenefit.benefitBalance.financial
  • Added Element Change value set from Common Languages to All Languages
    • ExplanationOfBenefit.benefitBalance.financial.type
  • Added Element Change max value set from All Languages to none
ExplanationOfBenefit.benefitBalance.financial.allowed[x] ExplanationOfBenefit.patient
  • Added Element Deleted
ExplanationOfBenefit.benefitBalance.financial.used[x] ExplanationOfBenefit.careTeam.responsible
  • Added Element Deleted
ExplanationOfBenefit.request ExplanationOfBenefit.careTeam.qualification
  • deleted Deleted
ExplanationOfBenefit.ruleset ExplanationOfBenefit.diagnosis.packageCode
  • deleted Deleted
ExplanationOfBenefit.originalRuleset ExplanationOfBenefit.item.subSite
  • deleted Deleted
ExplanationOfBenefit.requestProvider ExplanationOfBenefit.item.adjudication.value
  • deleted Deleted
ExplanationOfBenefit.requestOrganization ExplanationOfBenefit.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

 

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

13.10.2.1 13.10.4.1 Terminology Bindings

ExplanationOfBenefit.outcome ExplanationOfBenefit.payee.type ExplanationOfBenefit.payee.resourceType ExplanationOfBenefit.information.category ExplanationOfBenefit.careTeam.role ExplanationOfBenefit.careTeam.qualification ExplanationOfBenefit.diagnosis.diagnosis[x] ExplanationOfBenefit.diagnosis.type ExplanationOfBenefit.diagnosis.packageCode ExplanationOfBenefit.procedure.procedure[x] ExplanationOfBenefit.accident.type ExplanationOfBenefit.item.revenue ExplanationOfBenefit.item.detail.revenue ExplanationOfBenefit.item.detail.subDetail.revenue ExplanationOfBenefit.addItem.revenue ExplanationOfBenefit.addItem.detail.revenue ExplanationOfBenefit.item.category ExplanationOfBenefit.item.detail.category ExplanationOfBenefit.item.location[x] ExplanationOfBenefit.item.bodySite ExplanationOfBenefit.item.adjudication.category ExplanationOfBenefit.item.adjudication.reason ExplanationOfBenefit.item.detail.type ExplanationOfBenefit.item.detail.subDetail.type ExplanationOfBenefit.payment.type
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 Required Extensible Example

This value set includes Claim Type Codes codes.

ExplanationOfBenefit.subType A more granulat claim typecode ExampleClaimSubTypeCodes Example Example

This value set includes sample Claim SubType Codes 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 Use Required

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

ExplanationOfBenefit.priority ProcessPriorityCodes Preferred

This value set includes the financial processing priority codes.

ExplanationOfBenefit.fundsReserveRequested FundsReservationCodes Example Preferred

This value set includes funds reservation type codes.

ExplanationOfBenefit.fundsReserve Claim Processing Codes FundsReservationCodes Preferred

This value set includes funds reservation type codes.

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

This value set includes sample Related Claim Relationship Codes 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 type of payee Resource ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes ) Required

This value set includes Claim Processing Outcome codes.

ExplanationOfBenefit.decision PayeeResourceType ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Preferred

This value set includes Claim Adjudication Decision codes.

ExplanationOfBenefit.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example The valuset used for additional information category

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.specialty ExampleProviderQualificationCodes Example

This value set includes sample Provider Qualification codes.

ExplanationOfBenefit.supportingInfo.category Claim ClaimInformationCategoryCodes Preferred

This value set includes sample Information Category Codes codes.

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

This value set includes sample Exception Codes codes.

ExplanationOfBenefit.information.reason ExplanationOfBenefit.supportingInfo.reason MissingToothReasonCodes Example

This value set includes sample Missing Tooth Reason codes for the missing teeth codes.

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

This value set includes sample ICD-10 codes.

ExplanationOfBenefit.diagnosis.type Missing Tooth Reason Codes ExampleDiagnosisTypeCodes Preferred

This value set includes example Diagnosis Type codes.

ExplanationOfBenefit.diagnosis.onAdmission ExampleDiagnosisOnAdmissionCodes Preferred The role codes for the care team members.

This value set includes example Diagnosis on Admission codes.

ExplanationOfBenefit.procedure.type ExampleProcedureTypeCodes Example Preferred

This value set includes example Procedure Type codes.

ExplanationOfBenefit.procedure.procedure[x] Claim Care Team Role 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 Provider professional qualifications

Set of codes indicating the type of incident or accident.

ExplanationOfBenefit.item.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.item.category BenefitCategoryCodes Example Provider Qualification Codes

This value set includes examples of Benefit Category codes.

ExplanationOfBenefit.item.productOrService ICD10 Diagnostic codes USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.productOrServiceEnd ICD-10 Codes USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.modifier ModifierTypeCodes Example The

This value set includes sample Modifier type of the diagnosis: admitting, principal, discharge codes.

ExplanationOfBenefit.item.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

ExplanationOfBenefit.item.location[x] ExampleServicePlaceCodes Example Diagnosis Type Codes

This value set includes a smattering of Service Place codes.

ExplanationOfBenefit.item.bodySite.site OralSiteCodes Example The DRG codes associated with the diagnosis

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

ExplanationOfBenefit.item.bodySite.subSite SurfaceCodes Example

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

ExplanationOfBenefit.item.reviewOutcome.decision Example Diagnosis Related Group ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Preferred

This value set includes Claim Adjudication Decision codes.

ExplanationOfBenefit.item.reviewOutcome.reason ClaimAdjudicationDecisionReasonCodes Example ICD10 Procedure

This value set includes example Claim Adjudication Decision Reason codes.

ExplanationOfBenefit.item.adjudication.category AdjudicationValueCodes Preferred

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.item.adjudication.reason AdjudicationReasonCodes Example

This value set includes smattering of Adjudication Reason codes.

ExplanationOfBenefit.item.detail.revenue ICD-10 Procedure Codes ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.item.detail.category BenefitCategoryCodes Example Type

This value set includes examples of accident: work place, auto, etc. Benefit Category codes.

ExplanationOfBenefit.item.detail.productOrService USCLSCodes Required Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.productOrServiceEnd ActIncidentCode USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.modifier ModifierTypeCodes Example Codes for the revenue or cost centers supplying the service and/or products.

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 ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center Codes codes.

ExplanationOfBenefit.item.detail.subDetail.category ExplanationOfBenefit.addItem.category ExplanationOfBenefit.addItem.detail.category ExplanationOfBenefit.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glasses BenefitCategoryCodes Example

This value set includes examples of Benefit SubCategory Codes Category codes.

ExplanationOfBenefit.item.service ExplanationOfBenefit.item.detail.service ExplanationOfBenefit.item.detail.subDetail.service ExplanationOfBenefit.addItem.service ExplanationOfBenefit.addItem.detail.service ExplanationOfBenefit.item.detail.subDetail.productOrService Allowable service and product codes USCLSCodes Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd USCLS Codes USCLSCodes Example

This value set includes a smattering of USCLS codes.

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

This value set includes sample Modifier type Codes codes.

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

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

ExplanationOfBenefit.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.addItem.category BenefitCategoryCodes Example Program Reason Codes

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 ModifierTypeCodes Example Service Place Codes

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 Oral Site Codes OralSiteCodes Example

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

ExplanationOfBenefit.item.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 Surface Codes

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 Adjudication Value Codes

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.modifier ModifierTypeCodes Example Adjudication reason

This value set includes sample Modifier type codes.

ExplanationOfBenefit.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example Adjudication Reason Codes

This value set includes sample Revenue Center codes.

ExplanationOfBenefit.addItem.detail.subDetail.productOrService Service, Product, Rx Dispense, Rx Compound etc. USCLSCodes Required Example

This value set includes a smattering of USCLS codes.

ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd ActInvoiceGroupCode 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 Example ExamplePaymentTypeCodes Preferred

This value set includes example Payment Type Codes codes.

ExplanationOfBenefit.payment.adjustmentReason Payment Adjustment reason codes. PaymentAdjustmentReasonCodes Example Preferred

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

ExplanationOfBenefit.form ExplanationOfBenefit.formCode FormCodes Example The forms

This value set includes a sample set of Forms codes.

ExplanationOfBenefit.processNote.class Example Form Codes
ExplanationOfBenefit.processNote.type The presentation types of notes. NoteType Required Extensible NoteType

The presentation types of notes.

ExplanationOfBenefit.processNote.language A human language. Extensible , but limited to All 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)

  Common Languages starter
ExplanationOfBenefit.benefitBalance.category Benefit categories such as: oral, medical, vision etc. BenefitCategoryCodes Example

This value set includes examples of Benefit Category Codes codes.

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

This value set includes a smattering of Network Type Codes type codes.

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

This value set includes a smattering of Unit Type Codes type codes.

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

This value set includes a smattering of Benefit Term Codes codes.

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

This value set includes a smattering of Benefit Type Codes 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.

13.10.3 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 ) 		26 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 58 Resources
organization item-udi reference The reference to the providing organization UDI associated with a line item product or service ExplanationOfBenefit.organization ExplanationOfBenefit.item.udi
( Organization 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 ) 		60 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 )