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13.10.6 Resource ExplanationOfBenefit - Mappings

Financial Management Work Group

Maturity Level : N/A

Ballot Status : Informative

Compartments : Encounter , Patient , Practitioner , RelatedPerson

Mappings for the explanationofbenefit resource. resource (see Mappings to Other Standards for further information & status).

13.10.6.1 Mappings for HL7 v2 Mapping (http://hl7.org/v2) FiveWs Pattern (http://hl7.org/fhir/fivews)

        provider

ExplanationOfBenefit	identifier     status
type     identifier	subType FiveWs.identifier
patient     status	billablePeriod FiveWs.status
created     type	enterer FiveWs.class
insurer     subType	provider FiveWs.class
organization     use	referral FiveWs.class
facility     patient	claim FiveWs.subject[x]
claimResponse     billablePeriod	outcome FiveWs.done[x]
disposition     created	related FiveWs.recorded
claim     enterer	relationship FiveWs.author
reference     insurer	prescription FiveWs.author
originalPrescription     provider	payee FiveWs.source
type     referral	resourceType FiveWs.cause
party     facility	information FiveWs.where[x]
sequence     claim	category FiveWs.why[x]
code         provider	timing[x] FiveWs.actor
value[x]         serviced[x]	reason FiveWs.done[x]
careTeam         location[x]	sequence FiveWs.where[x]

        responsible

13.10.6.2 Mappings for Workflow Pattern (http://hl7.org/fhir/workflow)         qualification

    item

diagnosis         sequence ExplanationOfBenefit         diagnosis[x]	type Event
packageCode     identifier	procedure Event.identifier
sequence     status	date Event.status
procedure[x]     type	precedence Event.code
insurance     patient	Coverage Event.subject
coverage     created	preAuthRef Event.occurrence[x]
accident     enterer	date Event.performer.agent
type     insurer	location[x] Event.performer.agent
employmentImpacted     facility	hospitalization Event.performer.location

        sequence

13.10.6.3 Mappings for HL7 v2 Mapping (http://hl7.org/v2)         diagnosisLinkId

13.10.6.2 Mappings for Canadian Dental Association eclaims standard (http://www.cda-adc.ca/en/services/cdanet/)

procedureLinkId         informationLinkId ExplanationOfBenefit         revenue	category         service
modifier     identifier	programCode         serviced[x]
location[x]     status	quantity         unitPrice
factor     type	net         udi
bodySite     subType	subSite         encounter
noteNumber     use	adjudication             category
reason     patient	amount             value
detail     billablePeriod	sequence             type
revenue     created	category             service
modifier     enterer	programCode             quantity
unitPrice     insurer	factor             net
udi     provider	noteNumber             adjudication
subDetail     referral	sequence                 type
revenue     facility	category                 service
modifier     claim	programCode                 quantity
unitPrice     claimResponse	factor                 net
udi     outcome	noteNumber                 adjudication
addItem     disposition	sequenceLinkId         revenue
category     related	service         modifier
fee         claim	noteNumber         adjudication
detail         relationship	revenue             category
service         reference	modifier             fee
noteNumber     prescription	adjudication
totalCost     originalPrescription	unallocDeductable
totalBenefit     payee	payment
type	adjustment         adjustmentReason
date         resource	amount         identifier
form         party	processNote         number
type     information	text
language         sequence	benefitBalance
category	subCategory         excluded
name         code	description         network
unit         timing[x]	term         financial
type         value[x]	allowed[x]
used[x]         reason	ExplanationOfBenefit
identifier     careTeam	status     type
subType         sequence	patient C06,C07,C08, C05, C04
billablePeriod         provider	created     enterer
insurer         responsible	B02
provider         role	B02
organization         qualification	B02
referral     diagnosis	B05     facility
claim         sequence	A02|G01
claimResponse         diagnosis[x]	A02|G01     outcome
disposition         type	related         claim
relationship         packageCode	reference     prescription
originalPrescription     procedure	payee F02
type         sequence	resourceType
party         date	B03, B04     information
sequence         procedure[x]	category
code     precedence	F23
timing[x]     insurance	F24 Coverage
value[x]         coverage	reason     careTeam
sequence         preAuthRef	provider         responsible
role     accident	qualification     diagnosis
sequence         date	diagnosis[x]
type	packageCode     procedure
sequence         location[x]	date         procedure[x]
precedence     item	insurance         coverage
preAuthRef         sequence	F03     accident
date         careTeamSequence	F02         type
location[x]         diagnosisSequence	employmentImpacted     hospitalization
item         procedureSequence	sequence F07
careTeamLinkId         informationSequence	diagnosisLinkId         procedureLinkId
informationLinkId         revenue	revenue
category
service	F06
modifier	F16 (required field for Oral) and F05
programCode
serviced[x]	F09
location[x]
quantity
unitPrice	F12
factor	F13/F14
net	F13/F14
udi
bodySite	F10
subSite	F11
encounter
noteNumber
adjudication
category
reason
amount
value
detail
sequence	F07             type
revenue
category
service	F34/F35
modifier	F16 (required field for Oral) and F05
programCode
quantity
unitPrice	F13/F14
factor	F13/F14
net	F13/F14
udi
noteNumber
adjudication
subDetail
sequence	F07                 type
revenue
category
service	F34/F35
modifier	F16 (required field for Oral) and F05
programCode
quantity
unitPrice	F13/F14
factor	F13/F14
net	F13/F14
udi
noteNumber
adjudication
addItem
sequenceLinkId         itemSequence
revenue         detailSequence
category         subDetailSequence	F06
service
modifier	F16 (required field for Oral) and F05
fee	noteNumber         adjudication
detail         noteNumber	revenue
category         adjudication	F06             service
modifier     total	F16 (required field for Oral) and F05             fee
noteNumber         category	adjudication     totalCost
unallocDeductable         amount	totalBenefit
payment
type
adjustment
adjustmentReason
date
amount
identifier	G01, B.23
form	G42
processNote
number
type
text	G32
language
benefitBalance
category
subCategory
excluded
name
description
network
unit
term
financial
type
allowed[x]
used[x]