13.6 Resource ExplanationOfBenefit - Content

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..* CodeableConcept Finer grained claim type information --></subType>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider for the claim --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization for the claim --></organization>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claim -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resourceType><!-- 0..1 CodeableConcept organization | patient | practitioner | relatedperson --></resourceType>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <category><!-- 1..1 CodeableConcept Category of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 Coding Reason associated with the information --></reason>
 </information>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of careteam -->
  <provider><!-- 1..1 Reference(Practitioner|Organization) Member of the Care Team --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing practitioner -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's list of diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Type of Diagnosis --></type>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </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 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..1 Insurance or medical plan -->
  <coverage><!-- 0..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </insurance>
 <accident>  <!-- 0..1 Details of an accident -->
  <date value="[date]"/><!-- 0..1 When the accident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <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 -->
  <careTeamLinkId value="[positiveInt]"/><!-- 0..* Applicable careteam members -->
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureLinkId value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationLinkId value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Adjudication reason --></reason>
   <amount><!-- 0..1 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 CodeableConcept Group or type of product or service --></type>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 CodeableConcept Type of product or service --></type>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <service><!-- 0..1 CodeableConcept Billing Code --></service>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication SubDetail adjudication --></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 CodeableConcept Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items detail adjudication --></adjudication>
  </detail>
 </addItem>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment (if paid) -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
  <language><!-- 0..1 CodeableConcept Language --></language>
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit Category --></category>
  <subCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></subCategory>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

{
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : [{ CodeableConcept }], // Finer grained claim type information
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner) }, // Author
  "insurer" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider for the claim
  "organization" : { Reference(Organization) }, // Responsible organization for the claim
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "related" : [{ // Related Claims which may be revelant to processing this claim
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationRequest) }, // Original Prescription
  "payee" : { // Payee
    "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other
    "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "category" : { CodeableConcept }, // R!  Category of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 4:
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { Coding } // Reason associated with the information
  }],
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Number to covey order of careteam
    "provider" : { Reference(Practitioner|Organization) }, // R!  Member of the Care Team
    "responsible" : <boolean>, // Billing practitioner
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's list of diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Type of Diagnosis
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "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:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : { // Insurance or medical plan
    "coverage" : { Reference(Coverage) }, // Insurance information
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accident" : { // Details of an accident
    "date" : "<date>", // When the accident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamLinkId" : ["<positiveInt>"], // Applicable careteam members
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "procedureLinkId" : ["<positiveInt>"], // Applicable procedures
    "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Adjudication reason
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { CodeableConcept }, // R!  Group or type of product or service
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { CodeableConcept }, // R!  Type of product or service
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "service" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // SubDetail adjudication
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { CodeableConcept } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment (if paid)
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Reason for Payment adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "form" : { CodeableConcept }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanitory text
    "language" : { CodeableConcept } // Language
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit Category
    "subCategory" : { CodeableConcept }, // Benefit SubCategory
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 3:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }]
}

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:ExplanationOfBenefit.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ], ... ; # 0..* Finer grained claim type information
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:ExplanationOfBenefit.provider [ Reference(Practitioner) ]; # 0..1 Responsible provider for the claim
  fhir:ExplanationOfBenefit.organization [ Reference(Organization) ]; # 0..1 Responsible organization for the claim
  fhir:ExplanationOfBenefit.referral [ Reference(ReferralRequest) ]; # 0..1 Treatment Referral
  fhir:ExplanationOfBenefit.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:ExplanationOfBenefit.claim [ Reference(Claim) ]; # 0..1 Claim reference
  fhir:ExplanationOfBenefit.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Claim response reference
  fhir:ExplanationOfBenefit.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claim
    fhir:ExplanationOfBenefit.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:ExplanationOfBenefit.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:ExplanationOfBenefit.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original Prescription
  fhir:ExplanationOfBenefit.payee [ # 0..1 Payee
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ CodeableConcept ]; # 0..1 organization | patient | practitioner | relatedperson
    # ExplanationOfBenefit.payee.party[x] : 0..1 Party to receive the payable. One of these 2
      fhir:ExplanationOfBenefit.payee.partyIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.payee.partyReference [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]
  ];
  fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 Category of information
    fhir:ExplanationOfBenefit.information.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.information.timingDate [ date ]
      fhir:ExplanationOfBenefit.information.timingPeriod [ Period ]
    # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data or supporting information. One of these 4
      fhir:ExplanationOfBenefit.information.valueString [ string ]
      fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.information.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.information.valueReference [ Reference(Any) ]
    fhir:ExplanationOfBenefit.information.reason [ Coding ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Number to covey order of careteam
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Practitioner|Organization) ]; # 1..1 Member of the Care Team
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:ExplanationOfBenefit.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's list of diagnosis. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Type of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 0..1 Insurance or medical plan
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 0..1 Insurance information
    fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
  ];
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of an accident
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:ExplanationOfBenefit.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:ExplanationOfBenefit.item.careTeamLinkId [ positiveInt ], ... ; # 0..* Applicable careteam members
    fhir:ExplanationOfBenefit.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.procedureLinkId [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:ExplanationOfBenefit.item.informationLinkId [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:ExplanationOfBenefit.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.item.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. One of these 3
      fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:ExplanationOfBenefit.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:ExplanationOfBenefit.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ExplanationOfBenefit.item.adjudication.reason [ CodeableConcept ]; # 0..1 Adjudication reason
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitory value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:ExplanationOfBenefit.item.detail.type [ CodeableConcept ]; # 1..1 Group or type of product or service
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.item.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:ExplanationOfBenefit.item.detail.subDetail.type [ CodeableConcept ]; # 1..1 Type of product or service
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:ExplanationOfBenefit.item.detail.subDetail.service [ CodeableConcept ]; # 0..1 Billing Code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* SubDetail adjudication
      ], ...;
    ], ...;
    fhir:ExplanationOfBenefit.item.prosthesis [ # 0..1 Prosthetic details
      fhir:ExplanationOfBenefit.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:ExplanationOfBenefit.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:ExplanationOfBenefit.item.prosthesis.priorMaterial [ CodeableConcept ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ExplanationOfBenefit.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.addItem.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Added items details
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.addItem.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ExplanationOfBenefit.unallocDeductable [ Money ]; # 0..1 Unallocated deductable
  fhir:ExplanationOfBenefit.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment (if paid)
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Reason for Payment adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.note [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ExplanationOfBenefit.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.note.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.note.language [ CodeableConcept ]; # 0..1 Language
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
    fhir:ExplanationOfBenefit.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:ExplanationOfBenefit.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
      # ExplanationOfBenefit.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
]

See the Full Difference for further information