DSTU2 STU 3 Candidate
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This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

7.6 Resource ExplanationOfBenefit - Content Resource ExplanationOfBenefit - Content This resource is marked as a draft

This resource is marked as a draft .

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.
Financial Management Financial Management Work Group Work Group Maturity Level : 0 Maturity Level : 0 Compartments : Not linked to any defined compartments : Not linked to any defined compartments

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.

7.6.1 Scope and Usage Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft. This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft. The ExplanationOfBenefit resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patients coverage in respect of that Claim. This is the logical combination of the Claim, Claim Response and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage used and/or remaining. Todo

The ExplanationOfBenefit resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patients coverage in respect of that Claim.

This is the logical combination of the Claim, Claim Response and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage used and/or remaining.

Todo

7.6.2 Resource Content Resource Content

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . ExplanationOfBenefit Σ DomainResource Remittance resource Explanation of Benefit resource
. . . identifier Σ 0..* Identifier Business Identifier Business Identifier
. . request . claim[x] Σ 0..1 Claim reference
.... claimIdentifier Identifier
.... claimReference Reference ( Claim )
. . . claimResponse[x] Claim reference Σ 0..1 Claim response reference
.... claimResponseIdentifier Identifier
.... claimResponseReference Reference ( ClaimResponse )
. . outcome . subType Σ 0..* Coding Finer grained claim type information
Example Claim SubType Codes ( Example )
... ruleset Σ 0..1 code Coding complete | error Current specification followed
RemittanceOutcome Ruleset Codes ( Example ( Required )
... originalRuleset Σ 0..1 Coding Original specification followed
Ruleset Codes ( Example )
. . disposition . created Σ 0..1 dateTime Creation date
... billablePeriod Σ 0..1 Period Period for charge submission
... disposition Σ 0..1 string Disposition Message Disposition Message
. . ruleset . provider[x] Σ 0..1 Responsible provider for the claim
.... providerIdentifier Identifier
. . . . providerReference Reference ( Practitioner )
... organization[x] Σ 0..1 Responsible organization for the claim
.... organizationIdentifier Identifier
.... organizationReference Reference ( Organization )
... facility[x] Σ 0..1 Servicing Facility
.... facilityIdentifier Identifier
.... facilityReference Reference ( Location )
... related Σ 0..* BackboneElement Related Claims which may be revelant to processing this claimn
.... claim[x] Σ 0..1 Reference to the related claim
..... claimIdentifier Identifier
..... claimReference Reference ( Claim )
.... relationship Σ 0..1 Coding Resource version How the reference claim is related
Ruleset Codes Example Related Claim Relationship Codes ( Example )
.... reference Σ 0..1 Identifier Related file or case reference
... prescription[x] Σ 0..1 Prescription
.... prescriptionIdentifier Identifier
.... prescriptionReference Reference ( MedicationOrder | VisionPrescription )
... originalPrescription[x] Σ 0..1 Original Prescription
.... originalPrescriptionIdentifier Identifier
.... originalPrescriptionReference Reference ( MedicationOrder )
... payee Σ 0..1 BackboneElement Payee
.... type Σ 0..1 Coding Type of party: Subscriber, Provider, other
Payee Type Codes ( Example )
. . . . party[x] Σ 0..1 Party to receive the payable
... . originalRuleset . partyIdentifier Identifier
. . . . . partyReference Reference ( Practitioner | Organization | Patient | RelatedPerson )
... referral[x] Σ 0..1 Treatment Referral
.... referralIdentifier Identifier
.... referralReference Reference ( ReferralRequest )
... occurrenceCode Σ 0..* Coding Original version Occurrence Codes
Ruleset Codes Example Occurrance Codes ( Example ( )
... occurenceSpanCode Σ 0..* Coding Occurrence Span Codes
Example Occurrance Span Codes ( Example )
. . created . valueCode Σ 0..* Coding Value Codes
Example Value Codes ( Example )
... diagnosis Σ 0..* BackboneElement Diagnosis
.... sequence Σ 1..1 positiveInt Number to covey order of diagnosis
.... diagnosis Σ 1..1 Coding Patient's list of diagnosis
ICD-10 Codes ( Example )
... procedure Σ 0..* BackboneElement Procedures performed
.... sequence Σ 1..1 positiveInt Procedure sequence for reference
.... date Σ 0..1 dateTime Creation When the procedure was performed
.... procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
..... procedureCoding Coding
..... procedureReference Reference ( Procedure )
... specialCondition Σ 0..* Coding List of special Conditions
Conditions Codes ( Example )
... patient[x] Σ 1..1 The subject of the Products and Services
.... patientIdentifier Identifier
.... patientReference Reference ( Patient )
... precedence Σ 0..1 positiveInt Precedence (primary, secondary, etc.)
... coverage Σ 1..1 BackboneElement Insurance or medical plan
.... coverage[x] Σ 1..1 Insurance information
..... coverageIdentifier Identifier
..... coverageReference Reference ( Coverage )
.... preAuthRef Σ 0..* string Pre-Authorization/Determination Reference
... accidentDate Σ 0..1 date When the accident occurred
. . organization . accidentType Σ 0..1 Coding The nature of the accident
ActIncidentCode ( Required )
... accidentLocation[x] Σ 0..1 Accident Place
.... accidentLocationAddress Address
.... accidentLocationReference Reference ( Organization Location )
. . . interventionException Insurer Σ 0..* Coding Intervention and exception code (Pharma)
Intervention Codes ( Example )
... onset Σ 0..* BackboneElement Condition related Onset related dates and codes
.... time[x] Σ 0..1 Illness, injury or treatable condition date
..... timeDate date
..... timePeriod Period
.... type Σ 0..1 Coding Onset of what
Example Onset Type (Reason) Codes ( Example )
. . requestProvider . employmentImpacted Σ 0..1 Period Period unable to work
... hospitalization Σ 0..1 Period Period in hospital
... item Σ 0..* BackboneElement Goods and Services
.... sequence Σ 1..1 positiveInt Service instance
.... type Σ 1..1 Coding Group or type of product or service
ActInvoiceGroupCode ( Required )
.... provider[x] Σ 0..1 Responsible practitioner
..... providerIdentifier Identifier
..... providerReference Reference ( Practitioner )
. . . . supervisor[x] Responsible practitioner Σ 0..1 Supervising Practitioner
..... supervisorIdentifier Identifier
. . . . requestOrganization . supervisorReference Reference ( Practitioner )
. . . . providerQualification Σ 0..1 Coding Type, classification or Specialization
Example Provider Qualification Codes ( Example )
.... diagnosisLinkId Σ 0..* positiveInt Applicable diagnoses
.... service Σ 1..1 Coding Item Code
USCLS Codes ( Example )
.... serviceModifier Σ 0..* Coding Service/Product modifiers
Example Service Modifier Codes ( Example )
.... modifier Σ 0..* Coding Service/Product billing modifiers
Modifier type Codes ( Example )
.... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] Σ 0..1 Date or dates of Service
..... servicedDate date
..... servicedPeriod Period
.... place Σ 0..1 Coding Place of service
Example Service Place Codes ( Example )
.... quantity Σ 0..1 SimpleQuantity Count of Products or Services
.... unitPrice Σ 0..1 Money Fee, charge or cost per point
.... factor Σ 0..1 decimal Price scaling factor
.... points Σ 0..1 decimal Difficulty scaling factor
.... net Σ 0..1 Money Total item cost
.... udi Σ 0..* Reference ( Organization Device ) Responsible organization Unique Device Identifier
. . . . bodySite Σ 0..1 Coding Service Location
Oral Site Codes ( Example )
.... subSite Σ 0..* Coding Service Sub-location
Surface Codes ( Example )
.... noteNumber Σ 0..* positiveInt List of note numbers which apply
.... adjudication Σ 0..* BackboneElement Adjudication details
..... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
..... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
..... amount Σ 0..1 Money Monetary amount
..... value Σ 0..1 decimal Non-monitory value
.... detail Σ 0..* BackboneElement Additional items
..... sequence Σ 1..1 positiveInt Service instance
..... type Σ 1..1 Coding Group or type of product or service
ActInvoiceGroupCode ( Required )
..... service Σ 1..1 Coding Additional item codes
USCLS Codes ( Example )
..... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
..... quantity Σ 0..1 SimpleQuantity Count of Products or Services
..... unitPrice Σ 0..1 Money Fee, charge or cost per point
..... factor Σ 0..1 decimal Price scaling factor
..... points Σ 0..1 decimal Difficulty scaling factor
..... net Σ 0..1 Money Total additional item cost
..... udi Σ 0..* Reference ( Device ) Unique Device Identifier
..... adjudication Σ 0..* BackboneElement Detail adjudication
...... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
...... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
...... amount Σ 0..1 Money Monetary amount
...... value Σ 0..1 decimal Non-monitory value
..... subDetail Σ 0..* BackboneElement Additional items
...... sequence Σ 1..1 positiveInt Service instance
...... type Σ 1..1 Coding Type of product or service
ActInvoiceGroupCode ( Required )
...... service Σ 1..1 Coding Additional item codes
USCLS Codes ( Example )
...... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
...... quantity Σ 0..1 SimpleQuantity Count of Products or Services
...... unitPrice Σ 0..1 Money Fee, charge or cost per point
...... factor Σ 0..1 decimal Price scaling factor
...... points Σ 0..1 decimal Difficulty scaling factor
...... net Σ 0..1 Money Net additional item cost
...... udi Σ 0..* Reference ( Device ) Unique Device Identifier
...... adjudication Σ 0..* BackboneElement SubDetail adjudication
....... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
....... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
....... amount Σ 0..1 Money Monetary amount
....... value Σ 0..1 decimal Non-monitory value
.... prosthesis Σ 0..1 BackboneElement Prosthetic details
..... initial Σ 0..1 boolean Is this the initial service
..... priorDate Σ 0..1 date Initial service Date
..... priorMaterial Σ 0..1 Coding Prosthetic Material
Oral Prostho Material type Codes ( Example )
... addItem Σ 0..* BackboneElement Insurer added line items
.... sequenceLinkId Σ 0..* positiveInt Service instances
.... service Σ 1..1 Coding Group, Service or Product
USCLS Codes ( Example )
.... fee Σ 0..1 Money Professional fee or Product charge
.... noteNumberLinkId Σ 0..* positiveInt List of note numbers which apply
.... adjudication Σ 0..* BackboneElement Added items adjudication
..... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
..... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
..... amount Σ 0..1 Money Monetary amount
..... value Σ 0..1 decimal Non-monitory value
.... detail Σ 0..* BackboneElement Added items details
..... service Σ 1..1 Coding Service or Product
USCLS Codes ( Example )
..... fee Σ 0..1 Money Professional fee or Product charge
..... adjudication Σ 0..* BackboneElement Added items detail adjudication
...... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
...... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
...... amount Σ 0..1 Money Monetary amount
...... value Σ 0..1 decimal Non-monitory value
... missingTeeth Σ 0..* BackboneElement Only if type = oral
.... tooth Σ 1..1 Coding Tooth Code
Teeth Codes ( Example )
.... reason Σ 0..1 Coding Reason for missing
Missing Tooth Reason Codes ( Example )
.... extractionDate Σ 0..1 date Date of Extraction
... totalCost Σ 0..1 Money Total Cost of service from the Claim
... unallocDeductable Σ 0..1 Money Unallocated deductable
... totalBenefit Σ 0..1 Money Total benefit payable for the Claim
... paymentAdjustment Σ 0..1 Money Payment adjustment for non-Claim issues
... paymentAdjustmentReason Σ 0..1 Coding Reason for Payment adjustment
Payment Adjustment Reason Codes ( Extensible )
... paymentDate Σ 0..1 date Expected data of Payment
... paymentAmount Σ 0..1 Money Payment amount
... paymentRef Σ 0..1 Identifier Payment identifier
... reserved Σ 0..1 Coding Funds reserved status
Funds Reservation Codes ( Example )
... form Σ 0..1 Coding Printed Form Identifier
Form Codes ( Required )
... note Σ 0..* BackboneElement Processing notes
.... number Σ 0..1 positiveInt Note Number for this note
.... type Σ 0..1 Coding display | print | printoper
NoteType ( Required )
.... text Σ 0..1 string Note explanitory text
... benefitBalance Σ 0..* BackboneElement Balance by Benefit Category
.... category Σ 1..1 Coding Benefit Category
Benefit Category Codes ( Example )
.... subCategory Σ 0..1 Coding Benefit SubCategory
Benefit SubCategory Codes ( Example )
.... network Σ 0..1 Coding In or out of network
Network Type Codes ( Example )
.... unit Σ 0..1 Coding Individual or family
Unit Type Codes ( Example )
.... term Σ 0..1 Coding Annual or lifetime
Benefit Term Codes ( Example )
.... financial Σ 0..* BackboneElement Benefit Summary
..... type Σ 1..1 Coding Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... benefit[x] Σ 0..1 Benefits allowed
...... benefitUnsignedInt unsignedInt
...... benefitQuantity Money
..... benefitUsed[x] Σ 0..1 Benefits used
...... benefitUsedUnsignedInt unsignedInt
...... benefitUsedQuantity Money

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

ExplanationOfBenefit ( ( DomainResource ) The Response business identifier The Response Business Identifier identifier : : Identifier [0..*] [0..*] Original request resource reference The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number request claim[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Claim » ) » Transaction status: error, complete The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number outcome claimResponse[x] : Type [0..1] « Identifier : code | Reference [0..1] « ( ClaimResponse ) » The outcome of the processing. (Strength=Required) A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType RemittanceOutcome ! » subType : Coding [0..*] « A more granulat claim typecode (Strength=Example) Example Claim SubType ?? » The version of the specification on which this instance relies ruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The version of the specification from which the original instance was created originalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The date when the EOB was created created : dateTime [0..1] The billable period for which charges are being submitted billablePeriod : Period [0..1] A description of the status of the adjudication A description of the status of the adjudication disposition : : string [0..1] The provider which is responsible for the claim provider[x] : Type [0..1] « Identifier [0..1] | Reference ( Practitioner ) » The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources The provider which is responsible for the claim ruleset organization[x] : Type [0..1] « Identifier : Coding | Reference [0..1] « ( Organization ) » The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Facility where the services were provided Ruleset facility[x] : Type [0..1] « Identifier ?? » | Reference ( Location ) » The style (standard) and version of the original material which was converted into this resource Prescription to support the dispensing of Pharmacy or Vision products originalRuleset prescription[x] : Type [0..1] « Identifier : | Reference ( MedicationOrder | VisionPrescription ) » Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription[x] : Type [0..1] « Identifier | Reference ( MedicationOrder ) » The referral resource which lists the date, practitioner, reason and other supporting information referral[x] : Type [0..1] « Identifier | Reference ( ReferralRequest ) » **Insert definition of Occurrence codes occurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example) Example Occurrance ?? » **Insert definition of Occurrence Span codes occurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example) Example Occurrance Span ?? » **Insert definition of Value codes valueCode : Coding [0..*] « Value code (Strength=Example) Example Value ?? » List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication specialCondition : Coding [0..*] « List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. (Strength=Example) Conditions ?? » Patient Resource patient[x] : Type [1..1] « Identifier [0..1] « | Reference ( Patient ) » The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Precedence (primary, secondary, etc.) Ruleset precedence : positiveInt [0..1] Date of an accident which these services are addressing accidentDate : date [0..1] Type of accident: work, auto, etc accidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! » Accident Place accidentLocation[x] : Type [0..1] « Address ?? » | Reference ( Location ) » The A list of intervention and exception codes which may influence the adjudication of the claim interventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example) Intervention ?? » The start and optional end dates of when the patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] The start and optional end dates of when the patient was confined to a treatment center hospitalization : Period [0..1] The total cost of the services reported totalCost : Quantity ( Money ) [0..1] The amount of deductable applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) totalBenefit : Quantity ( Money ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible) Payment Adjustment Reason + » Estimated payment data paymentDate : date when the enclosed suite of services were performed or completed [0..1] Payable less any payment adjustment created paymentAmount : Quantity : dateTime ( Money [0..1] ) [0..1] The Insurer who produced this adjudicated response Payment identifer organization paymentRef : Identifier [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : Coding [0..1] « The forms codes. (Strength=Required) Form ! » RelatedClaims Other claims which are related to this claim such as prior claim versions or for related services claim[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Claim ) » For example prior or umbrella relationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... ?? » 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] Payee Type of Party to be reimbursed: Subscriber, provider, other type : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example) Payee Type ?? » Party to be reimbursed: Subscriber, provider, other party[x] : Type [0..1] « Identifier | Reference ( Practitioner | Organization » | Patient | RelatedPerson ) » Diagnosis The practitioner who is responsible for the services rendered to the patient Sequence of diagnosis which serves to order and provide a link requestProvider sequence : positiveInt [1..1] The diagnosis diagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » Procedure Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] « Coding : | Reference [0..1] « ( Procedure ); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? » Coverage Reference to the program or plan identification, underwriter or payor coverage[x] : Type [1..1] « Identifier | Reference ( Coverage ) » A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] Onset The start or start and end dates for the treatable condition time[x] : Type [0..1] « date | Period » Onset typifications eg. Start of pregnancy, start of illnes, etc type : Coding [0..1] « Condition related start, end and period codes (Strength=Example) Example Onset Type (Reason) ?? » Items A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » The practitioner who is responsible for the services rendered to the patient provider[x] : Type [0..1] « Identifier | Reference ( Practitioner » ) » The organization which is responsible for the services rendered to the patient The practitioner who is supervising the work of the servicing provider(s) requestOrganization supervisor[x] : Type [0..1] « Identifier : | Reference [0..1] « Organization ( Practitioner » ) » The qualification which is applicable for this service providerQualification : Coding [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? » Diagnosis applicable for this service or product line diagnosisLinkId : positiveInt [0..*] If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » Unusual circumstances which may influence adjudication serviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example) Example Service Modifier ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date | Period » Where the service was provided place : Coding [0..1] « Place where the service is rendered (Strength=Example) Example Service Place ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc) bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example) Oral Site ?? » A region or surface of the site, eg. limb region or tooth surface(s) subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example) Surface ?? » A list of note references to the notes provided below noteNumber : positiveInt [0..*] ItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Detail A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » DetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] SubDetail A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » The fee for an addittional service or product or charge service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : boolean [0..1] Date of the initial placement priorDate : date [0..1] Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Oral Prostho Material type ?? » AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] A code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] A list of note references to the notes provided below noteNumberLinkId : positiveInt [0..*] AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] MissingTeeth The code identifying which tooth is missing tooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example) Teeth ?? » Missing reason may be: E-extraction, O-other reason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? » The date of the extraction either known from records or patient reported estimate extractionDate : date [0..1] Notes An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : Coding [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc category : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » Network designation network : Coding [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed benefit[x] : Type [0..1] « unsignedInt | Quantity ( Money ) » Benefits used benefitUsed[x] : Type [0..1] « unsignedInt | Quantity ( Money ) » Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services payee [0..1] Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care coverage [1..1] Period, start and last dates of aspects of the Condition or related services onset [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] Third tier of goods and services subDetail [0..*] Second tier of goods and services detail [0..*] The materials and placement date of prior fixed prosthesis prosthesis [0..1] First tier of goods and services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons missingTeeth [0..*] Note text note [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template XML Template 

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider for the claim --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization for the claim --></organization[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>

 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>

 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <adjudication>  <!-- 0..* Detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <adjudication>  <!-- 0..* SubDetail adjudication -->
     <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
     <reason><!-- 0..1 Coding Adjudication reason --></reason>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>

</ExplanationOfBenefit>

JSON Template JSON Template 

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

  "identifier" : [{ Identifier }], // Business Identifier
  // claim[x]: Claim reference. One of these 2:

  "claimIdentifier" : { Identifier },
  "claimReference" : { Reference(Claim) },
  // claimResponse[x]: Claim response reference. One of these 2:

  "claimResponseIdentifier" : { Identifier },
  "claimResponseReference" : { Reference(ClaimResponse) },
  "subType" : [{ Coding }], // Finer grained claim type information
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission

  "disposition" : "<string>", // Disposition Message
  "
  "
  "
  "
  "
  "

  // provider[x]: Responsible provider for the claim. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization for the claim. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // facility[x]: Servicing Facility. One of these 2:

  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:

    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:

  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:

  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Payee
    "type" : { Coding }, // Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:

    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:

  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:

    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:

  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "coverage" : { // R!  Insurance or medical plan
    // coverage[x]: Insurance information. One of these 2:

    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:

  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:

    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:

    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:

    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "adjudication" : [{ // Detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "adjudication" : [{ // SubDetail adjudication
          "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "reason" : { Coding }, // Adjudication reason
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductable
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 2:

      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:

      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }]

}

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . ExplanationOfBenefit Σ DomainResource Remittance resource Explanation of Benefit resource
. . . identifier Σ 0..* Identifier Business Identifier Business Identifier
. . request . claim[x] Σ 0..1 Claim reference
.... claimIdentifier Identifier
.... claimReference Reference ( Claim )
. . . claimResponse[x] Claim reference Σ 0..1 Claim response reference
.... claimResponseIdentifier Identifier
.... claimResponseReference Reference ( ClaimResponse )
. . outcome . subType Σ 0..* Coding Finer grained claim type information
Example Claim SubType Codes ( Example )
... ruleset Σ 0..1 code Coding complete | error Current specification followed
RemittanceOutcome Ruleset Codes ( Example ( Required )
... originalRuleset Σ 0..1 Coding Original specification followed
Ruleset Codes ( Example )
. . disposition . created Σ 0..1 dateTime Creation date
... billablePeriod Σ 0..1 Period Period for charge submission
... disposition Σ 0..1 string Disposition Message Disposition Message
. . ruleset . provider[x] Σ 0..1 Responsible provider for the claim
.... providerIdentifier Identifier
. . . . providerReference Reference ( Practitioner )
... organization[x] Σ 0..1 Responsible organization for the claim
.... organizationIdentifier Identifier
.... organizationReference Reference ( Organization )
... facility[x] Σ 0..1 Servicing Facility
.... facilityIdentifier Identifier
.... facilityReference Reference ( Location )
... related Σ 0..* BackboneElement Related Claims which may be revelant to processing this claimn
.... claim[x] Σ 0..1 Reference to the related claim
..... claimIdentifier Identifier
..... claimReference Reference ( Claim )
.... relationship Σ 0..1 Coding Resource version How the reference claim is related
Ruleset Codes Example Related Claim Relationship Codes ( Example )
.... reference Σ 0..1 Identifier Related file or case reference
... prescription[x] Σ 0..1 Prescription
.... prescriptionIdentifier Identifier
.... prescriptionReference Reference ( MedicationOrder | VisionPrescription )
... originalPrescription[x] Σ 0..1 Original Prescription
.... originalPrescriptionIdentifier Identifier
.... originalPrescriptionReference Reference ( MedicationOrder )
... payee Σ 0..1 BackboneElement Payee
.... type Σ 0..1 Coding Type of party: Subscriber, Provider, other
Payee Type Codes ( Example )
. . . . party[x] Σ 0..1 Party to receive the payable
. . . . originalRuleset . partyIdentifier Identifier
. . . . . partyReference Reference ( Practitioner | Organization | Patient | RelatedPerson )
... referral[x] Σ 0..1 Treatment Referral
.... referralIdentifier Identifier
.... referralReference Reference ( ReferralRequest )
... occurrenceCode Σ 0..* Coding Original version Occurrence Codes
Ruleset Codes Example Occurrance Codes ( Example ( )
... occurenceSpanCode Σ 0..* Coding Occurrence Span Codes
Example Occurrance Span Codes ( Example )
. . created . valueCode Σ 0..* Coding Value Codes
Example Value Codes ( Example )
... diagnosis Σ 0..* BackboneElement Diagnosis
.... sequence Σ 1..1 positiveInt Number to covey order of diagnosis
.... diagnosis Σ 1..1 Coding Patient's list of diagnosis
ICD-10 Codes ( Example )
... procedure Σ 0..* BackboneElement Procedures performed
.... sequence Σ 1..1 positiveInt Procedure sequence for reference
.... date Σ 0..1 dateTime Creation When the procedure was performed
.... procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
..... procedureCoding Coding
..... procedureReference Reference ( Procedure )
... specialCondition Σ 0..* Coding List of special Conditions
Conditions Codes ( Example )
... patient[x] Σ 1..1 The subject of the Products and Services
.... patientIdentifier Identifier
.... patientReference Reference ( Patient )
... precedence Σ 0..1 positiveInt Precedence (primary, secondary, etc.)
... coverage Σ 1..1 BackboneElement Insurance or medical plan
.... coverage[x] Σ 1..1 Insurance information
..... coverageIdentifier Identifier
..... coverageReference Reference ( Coverage )
.... preAuthRef Σ 0..* string Pre-Authorization/Determination Reference
... accidentDate Σ 0..1 date When the accident occurred
. . organization . accidentType Σ 0..1 Coding The nature of the accident
ActIncidentCode ( Required )
... accidentLocation[x] Σ 0..1 Accident Place
.... accidentLocationAddress Address
.... accidentLocationReference Reference ( Organization Location )
. . . interventionException Insurer Σ 0..* Coding Intervention and exception code (Pharma)
Intervention Codes ( Example )
... onset Σ 0..* BackboneElement Condition related Onset related dates and codes
.... time[x] Σ 0..1 Illness, injury or treatable condition date
..... timeDate date
..... timePeriod Period
.... type Σ 0..1 Coding Onset of what
Example Onset Type (Reason) Codes ( Example )
. . requestProvider . employmentImpacted Σ 0..1 Period Period unable to work
... hospitalization Σ 0..1 Period Period in hospital
... item Σ 0..* BackboneElement Goods and Services
.... sequence Σ 1..1 positiveInt Service instance
.... type Σ 1..1 Coding Group or type of product or service
ActInvoiceGroupCode ( Required )
.... provider[x] Σ 0..1 Responsible practitioner
..... providerIdentifier Identifier
. . . . . providerReference Reference ( Practitioner )
.... supervisor[x] Σ 0..1 Supervising Practitioner
..... supervisorIdentifier Identifier
..... supervisorReference Reference ( Practitioner )
. . . . providerQualification Responsible practitioner Σ 0..1 Coding Type, classification or Specialization
Example Provider Qualification Codes ( Example )
. . . . diagnosisLinkId Σ 0..* positiveInt Applicable diagnoses
.... service Σ 1..1 Coding Item Code
USCLS Codes ( Example )
.... serviceModifier Σ 0..* Coding Service/Product modifiers
Example Service Modifier Codes ( Example )
.... modifier Σ 0..* Coding Service/Product billing modifiers
Modifier type Codes ( Example )
.... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] Σ 0..1 Date or dates of Service
..... servicedDate date
... . requestOrganization . servicedPeriod Period
. . . . place Σ 0..1 Coding Place of service
Example Service Place Codes ( Example )
.... quantity Σ 0..1 SimpleQuantity Count of Products or Services
.... unitPrice Σ 0..1 Money Fee, charge or cost per point
.... factor Σ 0..1 decimal Price scaling factor
.... points Σ 0..1 decimal Difficulty scaling factor
.... net Σ 0..1 Money Total item cost
.... udi Σ 0..* Reference ( Device ) Unique Device Identifier
.... bodySite Σ 0..1 Coding Service Location
Oral Site Codes ( Example )
.... subSite Σ 0..* Coding Service Sub-location
Surface Codes ( Example )
.... noteNumber Σ 0..* positiveInt List of note numbers which apply
.... adjudication Σ 0..* BackboneElement Adjudication details
..... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
..... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
..... amount Σ 0..1 Money Monetary amount
..... value Σ 0..1 decimal Non-monitory value
.... detail Σ 0..* BackboneElement Additional items
..... sequence Σ 1..1 positiveInt Service instance
..... type Σ 1..1 Coding Group or type of product or service
ActInvoiceGroupCode ( Required )
..... service Σ 1..1 Coding Additional item codes
USCLS Codes ( Example )
..... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
..... quantity Σ 0..1 SimpleQuantity Count of Products or Services
..... unitPrice Σ 0..1 Money Fee, charge or cost per point
..... factor Σ 0..1 decimal Price scaling factor
..... points Σ 0..1 decimal Difficulty scaling factor
..... net Σ 0..1 Money Total additional item cost
..... udi Σ 0..* Reference ( Organization Device ) Responsible organization Unique Device Identifier
. . . . . adjudication Σ 0..* BackboneElement Detail adjudication
...... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
...... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
...... amount Σ 0..1 Money Monetary amount
...... value Σ 0..1 decimal Non-monitory value
..... subDetail Σ 0..* BackboneElement Additional items
...... sequence Σ 1..1 positiveInt Service instance
...... type Σ 1..1 Coding Type of product or service
ActInvoiceGroupCode ( Required )
...... service Σ 1..1 Coding Additional item codes
USCLS Codes ( Example )
...... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
...... quantity Σ 0..1 SimpleQuantity Count of Products or Services
...... unitPrice Σ 0..1 Money Fee, charge or cost per point
...... factor Σ 0..1 decimal Price scaling factor
...... points Σ 0..1 decimal Difficulty scaling factor
...... net Σ 0..1 Money Net additional item cost
...... udi Σ 0..* Reference ( Device ) Unique Device Identifier
...... adjudication Σ 0..* BackboneElement SubDetail adjudication
....... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
....... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
....... amount Σ 0..1 Money Monetary amount
....... value Σ 0..1 decimal Non-monitory value
.... prosthesis Σ 0..1 BackboneElement Prosthetic details
..... initial Σ 0..1 boolean Is this the initial service
..... priorDate Σ 0..1 date Initial service Date
..... priorMaterial Σ 0..1 Coding Prosthetic Material
Oral Prostho Material type Codes ( Example )
... addItem Σ 0..* BackboneElement Insurer added line items
.... sequenceLinkId Σ 0..* positiveInt Service instances
.... service Σ 1..1 Coding Group, Service or Product
USCLS Codes ( Example )
.... fee Σ 0..1 Money Professional fee or Product charge
.... noteNumberLinkId Σ 0..* positiveInt List of note numbers which apply
.... adjudication Σ 0..* BackboneElement Added items adjudication
..... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
..... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
..... amount Σ 0..1 Money Monetary amount
..... value Σ 0..1 decimal Non-monitory value
.... detail Σ 0..* BackboneElement Added items details
..... service Σ 1..1 Coding Service or Product
USCLS Codes ( Example )
..... fee Σ 0..1 Money Professional fee or Product charge
..... adjudication Σ 0..* BackboneElement Added items detail adjudication
...... category Σ 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes ( Extensible )
...... reason Σ 0..1 Coding Adjudication reason
Adjudication Reason Codes ( Extensible )
...... amount Σ 0..1 Money Monetary amount
...... value Σ 0..1 decimal Non-monitory value
... missingTeeth Σ 0..* BackboneElement Only if type = oral
.... tooth Σ 1..1 Coding Tooth Code
Teeth Codes ( Example )
.... reason Σ 0..1 Coding Reason for missing
Missing Tooth Reason Codes ( Example )
.... extractionDate Σ 0..1 date Date of Extraction
... totalCost Σ 0..1 Money Total Cost of service from the Claim
... unallocDeductable Σ 0..1 Money Unallocated deductable
... totalBenefit Σ 0..1 Money Total benefit payable for the Claim
... paymentAdjustment Σ 0..1 Money Payment adjustment for non-Claim issues
... paymentAdjustmentReason Σ 0..1 Coding Reason for Payment adjustment
Payment Adjustment Reason Codes ( Extensible )
... paymentDate Σ 0..1 date Expected data of Payment
... paymentAmount Σ 0..1 Money Payment amount
... paymentRef Σ 0..1 Identifier Payment identifier
... reserved Σ 0..1 Coding Funds reserved status
Funds Reservation Codes ( Example )
... form Σ 0..1 Coding Printed Form Identifier
Form Codes ( Required )
... note Σ 0..* BackboneElement Processing notes
.... number Σ 0..1 positiveInt Note Number for this note
.... type Σ 0..1 Coding display | print | printoper
NoteType ( Required )
.... text Σ 0..1 string Note explanitory text
... benefitBalance Σ 0..* BackboneElement Balance by Benefit Category
.... category Σ 1..1 Coding Benefit Category
Benefit Category Codes ( Example )
.... subCategory Σ 0..1 Coding Benefit SubCategory
Benefit SubCategory Codes ( Example )
.... network Σ 0..1 Coding In or out of network
Network Type Codes ( Example )
.... unit Σ 0..1 Coding Individual or family
Unit Type Codes ( Example )
.... term Σ 0..1 Coding Annual or lifetime
Benefit Term Codes ( Example )
.... financial Σ 0..* BackboneElement Benefit Summary
..... type Σ 1..1 Coding Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... benefit[x] Σ 0..1 Benefits allowed
...... benefitUnsignedInt unsignedInt
...... benefitQuantity Money
..... benefitUsed[x] Σ 0..1 Benefits used
...... benefitUsedUnsignedInt unsignedInt
...... benefitUsedQuantity Money

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

ExplanationOfBenefit ( ( DomainResource ) The Response business identifier The Response Business Identifier identifier : : Identifier [0..*] [0..*] Original request resource reference The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number request claim[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Claim » ) » Transaction status: error, complete The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number outcome claimResponse[x] : Type [0..1] « Identifier : code | Reference [0..1] « ( ClaimResponse ) » The outcome of the processing. (Strength=Required) A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType RemittanceOutcome ! » subType : Coding [0..*] « A more granulat claim typecode (Strength=Example) Example Claim SubType ?? » The version of the specification on which this instance relies ruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The version of the specification from which the original instance was created originalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The date when the EOB was created created : dateTime [0..1] The billable period for which charges are being submitted billablePeriod : Period [0..1] A description of the status of the adjudication A description of the status of the adjudication disposition : : string [0..1] The provider which is responsible for the claim provider[x] : Type [0..1] « Identifier [0..1] | Reference ( Practitioner ) » The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources The provider which is responsible for the claim ruleset organization[x] : Type [0..1] « Identifier : Coding | Reference [0..1] « ( Organization ) » The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Facility where the services were provided Ruleset facility[x] : Type [0..1] « Identifier ?? » | Reference ( Location ) » The style (standard) and version of the original material which was converted into this resource Prescription to support the dispensing of Pharmacy or Vision products originalRuleset prescription[x] : Type [0..1] « Identifier : | Reference ( MedicationOrder | VisionPrescription ) » Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription[x] : Type [0..1] « Identifier | Reference ( MedicationOrder ) » The referral resource which lists the date, practitioner, reason and other supporting information referral[x] : Type [0..1] « Identifier | Reference ( ReferralRequest ) » **Insert definition of Occurrence codes occurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example) Example Occurrance ?? » **Insert definition of Occurrence Span codes occurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example) Example Occurrance Span ?? » **Insert definition of Value codes valueCode : Coding [0..*] « Value code (Strength=Example) Example Value ?? » List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication specialCondition : Coding [0..*] « List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. (Strength=Example) Conditions ?? » Patient Resource patient[x] : Type [1..1] « Identifier [0..1] « | Reference ( Patient ) » The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Precedence (primary, secondary, etc.) Ruleset precedence : positiveInt [0..1] Date of an accident which these services are addressing accidentDate : date [0..1] Type of accident: work, auto, etc accidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! » Accident Place accidentLocation[x] : Type [0..1] « Address ?? » | Reference ( Location ) » The A list of intervention and exception codes which may influence the adjudication of the claim interventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example) Intervention ?? » The start and optional end dates of when the patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] The start and optional end dates of when the patient was confined to a treatment center hospitalization : Period [0..1] The total cost of the services reported totalCost : Quantity ( Money ) [0..1] The amount of deductable applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) totalBenefit : Quantity ( Money ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding [0..1] « Payment Adjustment reason codes. (Strength=Extensible) Payment Adjustment Reason + » Estimated payment data paymentDate : date when the enclosed suite of services were performed or completed [0..1] Payable less any payment adjustment created paymentAmount : Quantity : dateTime ( Money [0..1] ) [0..1] The Insurer who produced this adjudicated response Payment identifer organization paymentRef : Identifier [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : Coding [0..1] « The forms codes. (Strength=Required) Form ! » RelatedClaims Other claims which are related to this claim such as prior claim versions or for related services claim[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Claim ) » For example prior or umbrella relationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... ?? » 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] Payee Type of Party to be reimbursed: Subscriber, provider, other type : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example) Payee Type ?? » Party to be reimbursed: Subscriber, provider, other party[x] : Type [0..1] « Identifier | Reference ( Practitioner | Organization » | Patient | RelatedPerson ) » Diagnosis The practitioner who is responsible for the services rendered to the patient Sequence of diagnosis which serves to order and provide a link requestProvider sequence : positiveInt [1..1] The diagnosis diagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » Procedure Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] « Coding : | Reference [0..1] « ( Procedure ); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? » Coverage Reference to the program or plan identification, underwriter or payor coverage[x] : Type [1..1] « Identifier | Reference ( Coverage ) » A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] Onset The start or start and end dates for the treatable condition time[x] : Type [0..1] « date | Period » Onset typifications eg. Start of pregnancy, start of illnes, etc type : Coding [0..1] « Condition related start, end and period codes (Strength=Example) Example Onset Type (Reason) ?? » Items A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » The practitioner who is responsible for the services rendered to the patient provider[x] : Type [0..1] « Identifier | Reference ( Practitioner » ) » The organization which is responsible for the services rendered to the patient The practitioner who is supervising the work of the servicing provider(s) requestOrganization supervisor[x] : Type [0..1] « Identifier : | Reference [0..1] « Organization ( Practitioner » ) » The qualification which is applicable for this service providerQualification : Coding [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? » Diagnosis applicable for this service or product line diagnosisLinkId : positiveInt [0..*] If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » Unusual circumstances which may influence adjudication serviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example) Example Service Modifier ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date | Period » Where the service was provided place : Coding [0..1] « Place where the service is rendered (Strength=Example) Example Service Place ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc) bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example) Oral Site ?? » A region or surface of the site, eg. limb region or tooth surface(s) subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example) Surface ?? » A list of note references to the notes provided below noteNumber : positiveInt [0..*] ItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Detail A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » DetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] SubDetail A service line number sequence : positiveInt [1..1] The type of product or service type : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! » The fee for an addittional service or product or charge service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Quantity ( 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] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Quantity ( Money ) [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : boolean [0..1] Date of the initial placement priorDate : date [0..1] Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Oral Prostho Material type ?? » AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] A code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] A list of note references to the notes provided below noteNumberLinkId : positiveInt [0..*] AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Adjudication reason such as limit reached reason : Coding [0..1] « Adjudication reason codes. (Strength=Extensible) Adjudication Reason + » Monitory amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] MissingTeeth The code identifying which tooth is missing tooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example) Teeth ?? » Missing reason may be: E-extraction, O-other reason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? » The date of the extraction either known from records or patient reported estimate extractionDate : date [0..1] Notes An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : Coding [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc category : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » Network designation network : Coding [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed benefit[x] : Type [0..1] « unsignedInt | Quantity ( Money ) » Benefits used benefitUsed[x] : Type [0..1] « unsignedInt | Quantity ( Money ) » Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services payee [0..1] Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care coverage [1..1] Period, start and last dates of aspects of the Condition or related services onset [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] Third tier of goods and services subDetail [0..*] Second tier of goods and services detail [0..*] The materials and placement date of prior fixed prosthesis prosthesis [0..1] First tier of goods and services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons missingTeeth [0..*] Note text note [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template XML Template 

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <claim[x]><!-- 0..1 Identifier|Reference(Claim) Claim reference --></claim[x]>
 <claimResponse[x]><!-- 0..1 Identifier|Reference(ClaimResponse) Claim response reference --></claimResponse[x]>
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider for the claim --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization for the claim --></organization[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>

 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>

 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <adjudication>  <!-- 0..* Detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <adjudication>  <!-- 0..* SubDetail adjudication -->
     <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
     <reason><!-- 0..1 Coding Adjudication reason --></reason>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 Coding Adjudication reason --></reason>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <category><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></category>
    <reason><!-- 0..1 Coding Adjudication reason --></reason>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(Money) Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>

</ExplanationOfBenefit>

JSON Template JSON Template 

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

  "identifier" : [{ Identifier }], // Business Identifier
  // claim[x]: Claim reference. One of these 2:

  "claimIdentifier" : { Identifier },
  "claimReference" : { Reference(Claim) },
  // claimResponse[x]: Claim response reference. One of these 2:

  "claimResponseIdentifier" : { Identifier },
  "claimResponseReference" : { Reference(ClaimResponse) },
  "subType" : [{ Coding }], // Finer grained claim type information
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission

  "disposition" : "<string>", // Disposition Message
  "
  "
  "
  "
  "
  "

  // provider[x]: Responsible provider for the claim. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization for the claim. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // facility[x]: Servicing Facility. One of these 2:

  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:

    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:

  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:

  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Payee
    "type" : { Coding }, // Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:

    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:

  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:

    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:

  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "coverage" : { // R!  Insurance or medical plan
    // coverage[x]: Insurance information. One of these 2:

    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:

  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:

    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:

    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:

    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "adjudication" : [{ // Detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "adjudication" : [{ // SubDetail adjudication
          "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "reason" : { Coding }, // Adjudication reason
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { Coding }, // Adjudication reason
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "category" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "reason" : { Coding }, // Adjudication reason
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductable
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 2:

      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:

      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }]

}

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

7.6.2.1 Terminology Bindings Terminology Bindings

ExplanationOfBenefit.ruleset
Path Definition Type Reference
ExplanationOfBenefit.subType A more granulat claim typecode Example ExplanationOfBenefit.outcome The outcome of the processing. Example Claim SubType Codes
ExplanationOfBenefit.ruleset
ExplanationOfBenefit.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version. Example Ruleset Codes
ExplanationOfBenefit.related.relationship Relationship of this claim to a related Claim Example Example Related Claim Relationship Codes
ExplanationOfBenefit.payee.type A code for the party to be reimbursed. Example Payee Type Codes
ExplanationOfBenefit.occurrenceCode Occurrence codes Example Example Occurrance Codes
ExplanationOfBenefit.occurenceSpanCode Occurrence Span codes Example Example Occurrance Span Codes
ExplanationOfBenefit.valueCode Value code Example Example Value Codes
ExplanationOfBenefit.diagnosis.diagnosis ICD10 Diagnostic codes Example ICD-10 Codes
ExplanationOfBenefit.procedure.procedure[x] ICD10 Procedure codes Example ICD-10 Procedure Codes
ExplanationOfBenefit.specialCondition List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. Example Conditions Codes
ExplanationOfBenefit.accidentType Type of accident: work place, auto, etc. Required RemittanceOutcome ActIncidentCode
ExplanationOfBenefit.interventionException Intervention and exception codes (Pharm) Example Intervention Codes
ExplanationOfBenefit.onset.type Condition related start, end and period codes Example Example Onset Type (Reason) Codes
ExplanationOfBenefit.item.type
ExplanationOfBenefit.originalRuleset ExplanationOfBenefit.item.detail.type
ExplanationOfBenefit.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc. Required The static and dynamic model to which contents conform, which may be business version or standard/version. ActInvoiceGroupCode
ExplanationOfBenefit.item.providerQualification Provider professional qualifications Example Ruleset Codes Example Provider Qualification Codes
ExplanationOfBenefit.item.service
ExplanationOfBenefit.item.detail.service
ExplanationOfBenefit.item.detail.subDetail.service
ExplanationOfBenefit.addItem.service
ExplanationOfBenefit.addItem.detail.service 		Allowable service and product codes Example USCLS Codes
ExplanationOfBenefit.item.serviceModifier Factors which may influce adjudication of services Example Example Service Modifier Codes
ExplanationOfBenefit.item.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. Example Modifier type Codes
ExplanationOfBenefit.item.programCode
ExplanationOfBenefit.item.detail.programCode
ExplanationOfBenefit.item.detail.subDetail.programCode 		Program specific reason codes Example Example Program Reason Codes
ExplanationOfBenefit.item.place Place where the service is rendered Example Example Service Place Codes
ExplanationOfBenefit.item.bodySite The code for the teeth, quadrant, sextant and arch Example Oral Site Codes
ExplanationOfBenefit.item.subSite The code for the tooth surface and surface combinations Example Surface Codes
ExplanationOfBenefit.item.adjudication.category
ExplanationOfBenefit.item.detail.adjudication.category
ExplanationOfBenefit.item.detail.subDetail.adjudication.category
ExplanationOfBenefit.addItem.adjudication.category
ExplanationOfBenefit.addItem.detail.adjudication.category 		The adjudication codes. Extensible Adjudication Codes
ExplanationOfBenefit.item.adjudication.reason
ExplanationOfBenefit.item.detail.adjudication.reason
ExplanationOfBenefit.item.detail.subDetail.adjudication.reason
ExplanationOfBenefit.addItem.adjudication.reason
ExplanationOfBenefit.addItem.detail.adjudication.reason 		Adjudication reason codes. Extensible Adjudication Reason Codes
ExplanationOfBenefit.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral) Example Oral Prostho Material type Codes
ExplanationOfBenefit.missingTeeth.tooth The codes for the teeth, subset of OralSites Example Teeth Codes
ExplanationOfBenefit.missingTeeth.reason Reason codes for the missing teeth Example Missing Tooth Reason Codes
ExplanationOfBenefit.paymentAdjustmentReason Payment Adjustment reason codes. Extensible Payment Adjustment Reason Codes
ExplanationOfBenefit.reserved For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes
ExplanationOfBenefit.form The forms codes. Required Form Codes
ExplanationOfBenefit.note.type The presentation types of notes. Required NoteType
ExplanationOfBenefit.benefitBalance.category Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
ExplanationOfBenefit.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
ExplanationOfBenefit.benefitBalance.network Code to classify in or out of network services Example Network Type Codes
ExplanationOfBenefit.benefitBalance.unit Unit covered/serviced - individual or family Example Unit Type Codes
ExplanationOfBenefit.benefitBalance.term Coverage unit - annual, lifetime Example Benefit Term Codes
ExplanationOfBenefit.benefitBalance.financial.type Deductable, visits, co-pay, etc. Example Benefit Type Codes

7.6.3 Search Parameters Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100.
Name Type Description Paths
identifier claimindentifier token The business The reference to the claim ExplanationOfBenefit.claimIdentifier
claimreference reference The reference to the claim ExplanationOfBenefit.claimReference
( Claim )
created date The creation date for the EOB ExplanationOfBenefit.created
disposition string The contents of the disposition message ExplanationOfBenefit.disposition
facilityidentifier token Facility responsible for the goods and services ExplanationOfBenefit.facilityIdentifier
facilityreference reference Facility responsible for the goods and services ExplanationOfBenefit.facilityReference
( Location )
identifier of the Explanation of Benefit token The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier
organizationidentifier token The reference to the providing organization ExplanationOfBenefit.organizationIdentifier
organizationreference reference The reference to the providing organization ExplanationOfBenefit.organizationReference
Links: Search ( Organization )
patientidentifier token | Version History The reference to the patient ExplanationOfBenefit.patientIdentifier
patientreference reference | Table of Contents The reference to the patient ExplanationOfBenefit.patientReference
( Patient | Compare to DSTU1 )
provideridentifier token | The reference to the provider ExplanationOfBenefit.providerIdentifier
providerreference reference | Propose a change The reference to the provider ExplanationOfBenefit.providerReference
( Practitioner try { var currentTabIndex = sessionStorage.getItem('fhir-resource-tab-index'); } catch(exception){ } if (!currentTabIndex) currentTabIndex = '0'; $( '#tabs' ).tabs({ active: currentTabIndex, activate: function( event, ui ) { var active = $('.selector').tabs('option', 'active'); currentTabIndex = ui.newTab.index(); document.activeElement.blur(); try { sessionStorage.setItem('fhir-resource-tab-index', currentTabIndex); } catch(exception){ } } });