13.10 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>
 <
 <</type>
 <</subType>

 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->

 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <
 <</enterer>

 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>

 <insurer><!-- 0..1 Reference(Organization) Insurer responsible for the EOB --></insurer>
 <</provider>
 <</organization>
 <</referral>

 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider for the claim --></provider>
 <referral><!-- 0..1 Reference(ServiceRequest) 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>
 <

 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <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>
  <</reference>

  <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 authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 0..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <</resourceType>
  <</party>

  <resource><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resource>
  <party><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party>
 </payee>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->

  <category><!-- 1..1 CodeableConcept General class of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <</value[x]>

  <value[x]><!-- 0..1 boolean|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 -->
  <
  <</provider>
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of careteam -->
  <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|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..* List of Diagnosis -->
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of diagnosis -->

  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>

  <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>
 <
 <
  <</coverage>
  <

 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>

 </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>
 <</hospitalization>
 <
  <
  <
  <
  <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>

 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careteam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence 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>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>

  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <</serviced[x]>

  <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>
  <
  <</net>

  <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>
  <</subSite>

  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>

  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <
  <

  <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 Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->

  </adjudication>
  <
   <
   <</type>
   <</revenue>
   <</category>
   <</service>
   <</modifier>

  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <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>
   <
   <</net>

   <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>
   <
   <</adjudication>
   <
    <
    <</type>
    <</revenue>
    <</category>
    <</service>
    <</modifier>

   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <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>
    <
    <</net>

    <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>
    <
    <</adjudication>

    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Language if different from the resource --></adjudication>

   </subDetail>
  </detail>
 </item>
 <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</fee>
  <
  <</adjudication>
  <
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</fee>
   <
   <</adjudication>

 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <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>
  <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..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <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>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <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>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
   </subDetail>

  </detail>
 </addItem>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <

 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category>
  <amount><!-- 1..1 Money Monetary amount --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->

  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <

  <date value="[date]"/><!-- 0..1 Expected date of Payment -->

  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <</identifier>

  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>

 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <
  <</type>
  <

  <number value="[positiveInt]"/><!-- 0..1 Sequence number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanitory text -->

  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <</category>
  <</subCategory>
  <
  <
  <

  <category><!-- 1..1 CodeableConcept Type of services covered --></category>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->

  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
   <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
   <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

{
  "resourceType" : "",

  "resourceType" : "ExplanationOfBenefit",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
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  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "insurer" : { Reference(Organization) }, // Insurer responsible for the EOB
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider for the claim
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : "<code>", // queued | 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

  }],
  "
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    "
    "

  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other
    "resource" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Party to receive the payable
  },
  "
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  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class 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 5:

    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { Coding } // Reason associated with the information

  }],
  "
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  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Number to convey order of careteam
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Member of the Care Team
    "responsible" : <boolean>, // Billing practitioner
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization

  }],
  "
    "

  "diagnosis" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to convey order of diagnosis

    // diagnosis[x]: Patient's diagnosis. One of these 2:
    " },
    " },
    "
    "

    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "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) }

  }],
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  },
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  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : [{ // Insurance or medical plan
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) } // R!  Insurance information
  }],
  "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) }

  },
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  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamSequence" : ["<positiveInt>"], // Applicable careteam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "billcode" : { 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:
    " },
    " },
    " },
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    "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
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "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 }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitory value

    }],
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    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "billcode" : { 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 level adjudication details
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "billcode" : { 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 }] // Language if different from the resource

      }]
    }]
  }],
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      "
      "

  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "billcode" : { 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
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "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
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
      "subDetail" : [{ // Insurer added line items
        "billcode" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "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
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
      }]

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

  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    "amount" : { Money } // R!  Monetary amount
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument

  },
  "
  "
    "
    "
    "
    "

  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanitory text
    "language" : { CodeableConcept } // Language if different from the resource

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

  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Type of services covered
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount

      // allowed[x]: Benefits allowed. One of these 3:
      ">",
      ">",
      " },

      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },

      // used[x]: Benefits used. One of these 2:
      ">"
      " }

      "usedUnsignedInt" : "<unsignedInt>"
      "usedMoney" : { Money }

    }]
  }]
}