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.

The EOB Business Identifier.

The status of the resource instance.

The category of claim, eg, e.g, oral, pharmacy, vision, insitutional, institutional, professional.

Affects which fields and value sets are used.

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType. CMS Bill Type.

This may contain the local bill type codes such as the US UB-04 bill type code.

A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.

Patient Resource.

The billable period for which charges are being submitted.

The date when the EOB this resource was created.

The person who created the explanation of benefit.

The insurer which is responsible for the explanation of benefit.

The provider which is responsible for the claim.

The referral resource which lists the date, practitioner, reason and other supporting information.

Facility where the services were provided.

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

Processing outcome errror, partial or complete processing.

A description of the status of the adjudication.

Do we need a disposition code?

Other claims which are related to this claim such as prior claim versions or for related services.

Other claims which are related to this claim such as prior claim versions or for related services.

Do we need a relationship code?

For example example, prior or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains - eg e.g. Property/Casualy insurer claim # or Workers Compensation case # .

Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

The party to be reimbursed for the services.

Type of Party to be reimbursed: Subscriber, provider, other.

organization | patient | practitioner | relatedperson.

Party to be reimbursed: Subscriber, provider, other.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Sequence of the information element which serves to provide a link.

To provide a reference link.

The general class of the information supplied: information; exception; accident, employment; onset, etc.

This may contain the local bill type codes such as the US UB-04 bill type code.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.

This may contain the local bill type codes such as the US UB-04 bill type code.

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.

The members of the team who provided the overall service as well as their role and whether responsible and qualifications.

Role and Responsible may might not be required when there is only a single provider listed.

Sequence of careteam which serves to order and provide a link.

Required to maintain order of the careteam members.

The members of the team who provided the overall service.

The practitioner who is billing and responsible for the claimed services rendered to the patient.

The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.

The qualification which is applicable for this service.

Ordered list of patient diagnosis for which care is sought.

Sequence of diagnosis which serves to provide a link.

Required to allow line items to reference the diagnoses.

The diagnosis.

Required to adjudicate services rendered to condition presented.

The type of the Diagnosis, for example: admitting, primary, secondary, discharge.

Required to adjudicate services rendered to the mandated diagnosis grouping system.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Indication of whether the diagnosis was present on admission to a facility.

The package billing code, for example DRG, based on the assigned grouping code system.

Required to adjudicate services rendered to the mandated grouping system.

Ordered list of patient procedures performed to support the adjudication.

Sequence of procedures which serves to order and provide a link.

Required to maintain order of the procudures.

Date and optionally time the procedure was performed .

Required to adjudicate services rendered.

SB DateTime??

The procedure code.

Required to adjudicate services rendered.

Precedence (primary, secondary, etc.).

Health care programs and insurers are significant payors of health service costs.

Financial instrument by which payment information for health care.

Health care programs and insurers are significant payors of health service costs.

Reference to The instance number of the program or plan identification, underwriter or payor. Coverage which is the focus for adjudication. The Coverage against which the claim was adjudicated.

Need to To identify the issuer to target for processing and for coordination of benefit processing. which coverage is being applied..

A list of references from the Insurer Reference to which these services pertain. the program or plan identification, underwriter or payor.

To provide any pre=determination or prior authorization reference. Need to identify the issuer to target for processing and for coordination of benefit processing.

An accident which resulted in the need for healthcare services.

Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

Type of accident: work, auto, etc.

Coverage may be dependant on the type of accident.

Where the accident occurred.

The start and optional end dates First-tier of when the patient was confined to a treatment center. goods and services.

A service line number.

Careteam applicable for this service or product line.

Diagnosis applicable for this service or product line.

Procedures applicable for this service or product line.

Exceptions, special conditions and supporting information pplicable for this service or product line.

The type of reveneu revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

If this is an actual service or product line, ie. i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Item typification or modifiers codes, eg e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The date or dates when the enclosed suite of services were service or product was supplied, performed or completed.

Where the service was provided.

The number of repetitions of a service or product.

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.

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.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional additional 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.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

Physical service site on the patient (limb, tooth, etc). etc.).

A region or surface of the site, eg. e.g. limb region or tooth surface(s).

A billed item may include goods or services provided in multiple encounters.

A list of note references to the notes provided below.

The adjudications adjudication results.

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monitory amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Second tier Second-tier of goods and services.

A service line number.

The type of reveneu revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

If this is an actual service or product line, ie. i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Item typification or modifiers codes, eg e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The number of repetitions of a service or product.

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.

If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional additional 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.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

A list of note references to the notes provided below.

The adjudications adjudication results.

Third tier Third-tier of goods and services.

A service line number.

The type of reveneu revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

A code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

Item typification or modifiers codes, eg e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The number of repetitions of a service or product.

The fee for an addittional service or product or charge.

If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an addittional additional 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.

If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

A list of note references to the notes provided below.

The adjudications adjudication results.

The first tier first-tier service adjudications for payor added services.

List of input service items which this service line is intended to replace.

The type sequence number of reveneu or cost center providing the product and/or service. addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Health Care Service Type Codes The providers who are authorized for the services rendered to identify the classification of service or benefits. patient.

If this is an actual service or product line, ie. i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Item typification or modifiers codes, eg e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

The fee charged For programs which require reason codes for the professional service inclusion or product. covering of this billed item under the program or sub-program.

A list The date or dates when the service or product was supplied, performed or completed.

Where the notes provided below. service was provided.

The adjudications results. number of repetitions of a service or product.

The second tier service adjudications If the item is a node then this is the fee for payor added services. the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The type concept of reveneu a Factor allows for a discount or cost center providing surcharge multiplier to be applied to a monetary amount.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service or product and/or service. 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.

If a fee is present the associated product/service code must be present.

Physical service site on the patient (limb, tooth, etc.).

Health Care Service Type Codes to identify the classification A region or surface of service the site, e.g. limb region or benefits. tooth surface(s).

A list of note references to the notes provided below.

The adjudication results.

The second-tier service adjudications for payor added services.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Item typification or modifiers codes, eg e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

The number of repetitions of a service or product.

If the item is a node then this is the fee charged for the professional product or service, otherwise this is the total of the fees for the children of the group.

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.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service or product. 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.

If a fee is present the associated product/service code must be present.

A list of note references to the notes provided below.

The adjudications adjudication results.

The total cost of third-tier service adjudications for payor added services.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the services reported. Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

This May impact on adjudication.

The number of repetitions of a service or product.

If the item is a check value that node then this is the receiver calculates and returns. fee for the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The amount concept of deductable a Factor allows for a discount or surcharge multiplier to be applied which was not allocated to any particular a monetary amount.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service line. 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.

If a fee is present the associated product/service code must be present.

Total amount A list of benefit payable (Equal note references to sum of the Benefit notes provided below.

The adjudication results.

Totals for amounts from all detail lines and additions less submitted, co-pays, benefits payable etc.

Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc.

Monitory amount associated with the Unallocated Deductable). code.

Payment details for the claim if the claim has been paid.

Whether this represents partial or complete payment of the claim.

Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Reason for the payment adjustment.

Estimated payment date.

Payable less any payment adjustment.

Payment identifer. identifier.

The form to be used for printing the content.

Note text.

An integer associated with each note which may be referred to from each service line item.

The note purpose: Print/Display.

The note text.

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" "en" for English, or "en-US" "en-US" for American English versus "en-EN" "en-EN" for England English.

Balance by Benefit Category.

Dental, Vision, Medical, Pharmacy, Rehab etc.

True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.

A short name or tag for the benefit, for example MED01, or DENT2.

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.

Network designation.

Unit designation: individual or family.

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.

Benefits Used to date.

Deductable, visits, benefit amount.

Benefits allowed.

Benefits used.