DSTU2 FHIR Release 3 (STU)

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7.6 13.10 Resource ExplanationOfBenefit - Content

This resource is marked as a draft .
Financial Management Work Group Maturity Level : 0 2   Trial Use Compartments : Not linked to any defined compartments Encounter , Patient , Practitioner , RelatedPerson

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

7.6.1 13.10.1 Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft. The ExplanationOfBenefit resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patients patient's coverage in respect of that Claim.

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

Todo

7.6.2 13.10.2 Resource Content

Structure

Σ Remittance Σ Σ Resource version Original version Creation date Insurer Responsible practitioner Responsible organization
Name Flags Card. Type Description & Constraints doco
. . ExplanationOfBenefit DomainResource Explanation of Benefit resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . request . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus ( Required )
... type 0..1 CodeableConcept Type or discipline
Example Claim Type Codes ( Required )
... subType 0..* CodeableConcept Finer grained claim type information
Example Claim SubType Codes ( Example )
... patient 0..1 Reference ( Patient ) The subject of the Products and Services
... billablePeriod 0..1 Period Period for charge submission
... created 0..1 dateTime Creation date
... enterer 0..1 Reference ( Practitioner ) Author
... insurer 0..1 Reference ( Organization ) Insurer responsible for the EOB
... provider 0..1 Reference ( Practitioner ) Responsible provider for the claim
... organization 0..1 Reference ( Organization ) Responsible organization for the claim
... referral 0..1 Reference ( ReferralRequest ) Treatment Referral
... facility 0..1 Reference ( Location ) Servicing Facility
... claim 0..1 Reference ( Claim ) Claim reference
. . outcome . claimResponse Σ 0..1 Reference ( ClaimResponse ) Claim response reference
... outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome Claim Processing Codes ( Required Example )
. . . disposition 0..1 string Disposition Message
. . ruleset . related Σ 0..* BackboneElement Related Claims which may be revelant to processing this claim
.... claim 0..1 Coding Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Ruleset Example Related Claim Relationship Codes ( Example )
. . originalRuleset . . reference Σ 0..1 Identifier Related file or case reference
... prescription 0..1 Reference ( MedicationRequest | VisionPrescription ) Prescription authorizing services or products
... originalPrescription 0..1 Reference ( MedicationRequest ) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Party to be paid any benefits payable
.... type 0..1 CodeableConcept Type of party: Subscriber, Provider, other
Claim Payee Type Codes ( Example )
.... resourceType 0..1 CodeableConcept organization | patient | practitioner | relatedperson
PayeeResourceType ( Required )
.... party 0..1 Reference ( Practitioner | Organization | Patient | RelatedPerson ) Party to receive the payable
... information 0..* BackboneElement Exceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept General class of information
Claim Information Category Codes ( Example )
.... code 0..1 CodeableConcept Type of information
Exception Codes ( Example )
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Additional Data or supporting information
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference ( Any )
.... reason 0..1 Coding Reason associated with the information
Ruleset Missing Tooth Reason Codes ( Example )
. . created . careTeam Σ 0..* BackboneElement Care Team members
.... sequence 1..1 positiveInt Number to covey order of careteam
.... provider 1..1 Reference ( Practitioner | Organization ) Member of the Care Team
.... responsible 0..1 boolean Billing practitioner
.... role 0..1 CodeableConcept Role on the team
Claim Care Team Role Codes ( Example )
.... qualification 0..1 CodeableConcept Type, classification or Specialization
Example Provider Qualification Codes ( Example )
... diagnosis 0..* BackboneElement List of Diagnosis
.... sequence 1..1 positiveInt Number to covey order of diagnosis
.... diagnosis[x] 1..1 Patient's diagnosis
ICD-10 Codes ( Example )
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference ( Condition )
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example )
.... packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
... procedure 0..* BackboneElement Procedures performed
.... sequence 1..1 positiveInt Procedure sequence for reference
.... date 0..1 dateTime When the procedure was performed
. . organization . . procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference ( Procedure )
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance 0..1 BackboneElement Insurance or medical plan
.... coverage 0..1 Reference ( Organization Coverage ) Insurance information
. . requestProvider . . preAuthRef Σ 0..* string Pre-Authorization/Determination Reference
... accident 0..1 BackboneElement Details of an accident
.... date 0..1 date When the accident occurred
.... type 0..1 CodeableConcept The nature of the accident
ActIncidentCode ( Required )
.... location[x] 0..1 Accident Place
..... locationAddress Address
..... locationReference Reference ( Practitioner Location )
. . . employmentImpacted 0..1 Period Period unable to work
. . requestOrganization . hospitalization Σ 0..1 Period Period in hospital
... item 0..* BackboneElement Goods and Services
.... sequence 1..1 positiveInt Service instance
.... careTeamLinkId 0..* positiveInt Applicable careteam members
.... diagnosisLinkId 0..* positiveInt Applicable diagnoses
.... procedureLinkId 0..* positiveInt Applicable procedures
.... informationLinkId 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
.... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
.... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] 0..1 Date or dates of Service
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service
Example Service Place Codes ( Example )
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference ( Organization Location )
. . . . quantity 0..1 SimpleQuantity Count of Products or Services
.... unitPrice 0..1 Money Fee, charge or cost per point
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference ( Device ) Unique Device Identifier
.... bodySite 0..1 CodeableConcept Service Location
Oral Site Codes ( Example )
.... subSite 0..* CodeableConcept Service Sub-location
Surface Codes ( Example )
.... encounter 0..* Reference ( Encounter ) Encounters related to this billed item
.... noteNumber 0..* positiveInt List of note numbers which apply
.... adjudication 0..* BackboneElement Adjudication details
..... category 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes ( Example )
..... reason 0..1 CodeableConcept Explanation of Adjudication outcome
Adjudication Reason Codes ( Example )
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitory value
.... detail 0..* BackboneElement Additional items
..... sequence 1..1 positiveInt Service instance
..... type 1..1 CodeableConcept Group or type of product or service
ActInvoiceGroupCode ( Required )
..... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
..... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
..... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
..... quantity 0..1 SimpleQuantity Count of Products or Services
..... unitPrice 0..1 Money Fee, charge or cost per point
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total additional item cost
..... udi 0..* Reference ( Device ) Unique Device Identifier
..... noteNumber 0..* positiveInt List of note numbers which apply
..... adjudication 0..* see adjudication Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... sequence 1..1 positiveInt Service instance
...... type 1..1 CodeableConcept Type of product or service
ActInvoiceGroupCode ( Required )
...... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
...... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
...... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
...... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
...... quantity 0..1 SimpleQuantity Count of Products or Services
...... unitPrice 0..1 Money Fee, charge or cost per point
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Net additional item cost
...... udi 0..* Reference ( Device ) Unique Device Identifier
...... noteNumber 0..* positiveInt List of note numbers which apply
...... adjudication 0..* see adjudication Language if different from the resource
... addItem 0..* BackboneElement Insurer added line items
.... sequenceLinkId 0..* positiveInt Service instances
.... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
.... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
.... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... fee 0..1 Money Professional fee or Product charge
. . . . noteNumber 0..* positiveInt List of note numbers which apply
.... adjudication 0..* see adjudication Added items adjudication
.... detail 0..* BackboneElement Added items details
..... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
..... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
..... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... fee 0..1 Money Professional fee or Product charge
..... noteNumber 0..* positiveInt List of note numbers which apply
..... adjudication 0..* see adjudication Added items detail adjudication
... totalCost 0..1 Money Total Cost of service from the Claim
... unallocDeductable 0..1 Money Unallocated deductable
... totalBenefit 0..1 Money Total benefit payable for the Claim
... payment 0..1 BackboneElement Payment (if paid)
.... type 0..1 CodeableConcept Partial or Complete
Example Payment Type Codes ( Example )
.... adjustment 0..1 Money Payment adjustment for non-Claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the non-claim adjustment
Payment Adjustment Reason Codes ( Example )
.... date 0..1 date Expected date of Payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Identifier of the payment instrument
... form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Example )
... processNote 0..* BackboneElement Processing notes
.... number 0..1 positiveInt Sequence number for this note
.... type 0..1 CodeableConcept display | print | printoper
NoteType ( Required )
.... text 0..1 string Note explanitory text
.... language 0..1 CodeableConcept Language if different from the resource
Common Languages ( Extensible but limited to All Languages )
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
.... subCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Network Type Codes ( Example )
.... unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
.... term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
.... financial 0..* BackboneElement Benefit Summary
..... type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

UML Diagram ( Legend )

ExplanationOfBenefit ( DomainResource ) The Response business identifier EOB Business Identifier identifier : Identifier [0..*] Original request The status of the resource reference instance (this element modifies the meaning of other elements) request status : code [0..1] A code specifying the state of the resource instance. (Strength=Required) ExplanationOfBenefitStatus ! The category of claim, eg, oral, pharmacy, vision, insitutional, professional type : CodeableConcept [0..1] The type or discipline-style of the claim (Strength=Required) Example Claim Type ! A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType subType : CodeableConcept [0..*] A more granulat claim typecode (Strength=Example) Example Claim SubType ?? Patient Resource patient : Reference [0..1] Patient The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the EOB was created created : dateTime [0..1] The person who created the explanation of benefit enterer : Reference [0..1] Practitioner The insurer which is responsible for the explanation of benefit insurer : Reference [0..1] Organization The provider which is responsible for the claim provider : Reference [0..1] Practitioner The provider which is responsible for the claim organization : Reference [0..1] Organization The referral resource which lists the date, practitioner, reason and other supporting information referral : Reference [0..1] ReferralRequest Facility where the services were provided facility : Reference [0..1] Location The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number claim : Reference [0..1] « Claim » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number claimResponse : Reference [0..1] ClaimResponse Transaction status: error, Processing outcome errror, partial or complete processing outcome : code CodeableConcept [0..1] « The outcome result of the processing. (Strength=Required) claim processing (Strength=Example) RemittanceOutcome ! » Claim Processing ?? A description of the status of the adjudication disposition : string [0..1] Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference [0..1] MedicationRequest | VisionPrescription 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 version prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' originalPrescription : Reference [0..1] MedicationRequest Precedence (primary, secondary, etc.) precedence : positiveInt [0..1] The start and optional end dates of when the style patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] The start and optional end dates of resource contents. This should be mapped when the patient was confined to a treatment center hospitalization : Period [0..1] The total cost of the allowable profiles services reported totalCost : Money [0..1] The amount of deductable applied which was not allocated to any particular service line unallocDeductable : Money [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) totalBenefit : Money [0..1] The form to be used for printing the content form : CodeableConcept [0..1] The forms codes. (Strength=Example) Form ?? RelatedClaim Other claims which are related to this and supporting resources claim such as prior claim versions or for related services ruleset claim : Coding Reference [0..1] « Claim For example prior or umbrella relationship : CodeableConcept [0..1] Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... ?? An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, provider, other type : CodeableConcept [0..1] A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? organization | patient | practitioner | relatedperson resourceType : CodeableConcept [0..1] The static type of payee Resource (Strength=Required) PayeeResourceType ! Party to be reimbursed: Subscriber, provider, other party : Reference [0..1] Practitioner | Organization | Patient | RelatedPerson SupportingInformation Sequence of the information element which serves to provide a link sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] The valuset used for additional information category codes. (Strength=Example) Claim Information Category ?? System and dynamic model code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which contents conform, care is sought which may be business version or standard/version. influence the adjudication code : CodeableConcept [0..1] The valuset used for additional information codes. (Strength=Example) Ruleset Exception ?? » The style (standard) date when or period to which this information refers timing[x] : Type [0..1] date | Period Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type [0..1] string | Quantity | Attachment | Reference ( Any ) 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 reason : Coding [0..1] Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? CareTeam Sequence of careteam which serves to order and version provide a link sequence : positiveInt [1..1] The members of the original material team who provided the overall service provider : Reference [1..1] Practitioner | Organization The practitioner who is billing and responsible for the claimed services rendered to the patient responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team role : CodeableConcept [0..1] The role codes for the care team members. (Strength=Example) Claim Care Team Role ?? The qualification which was converted into is applicable for this resource service originalRuleset qualification : Coding CodeableConcept [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? Diagnosis Sequence of diagnosis which serves to provide a link sequence : positiveInt [1..1] The static diagnosis diagnosis[x] : Type [1..1] CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? The type of the Diagnosis, for example: admitting, primary, secondary, discharge type : CodeableConcept [0..*] The type of the diagnosis: admitting, principal, discharge (Strength=Example) Example Diagnosis Type ?? The package billing code, for example DRG, based on the assigned grouping code system packageCode : CodeableConcept [0..1] The DRG codes associated with the diagnosis (Strength=Example) Example Diagnosis Related Gro... ?? Procedure Sequence of procedures which serves to order and dynamic model provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] CodeableConcept | Reference ( Procedure ); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? Insurance Reference to the program or plan identification, underwriter or payor coverage : Reference [0..1] Coverage A list of references from the Insurer to which contents conform, these services pertain preAuthRef : string [0..*] Accident Date of an accident which may be business version these services are addressing date : date [0..1] Type of accident: work, auto, etc type : CodeableConcept [0..1] Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! Where the accident occurred location[x] : Type [0..1] Address | Reference ( Location ) Item A service line number sequence : positiveInt [1..1] Careteam applicable for this service or standard/version. product line careTeamLinkId : positiveInt [0..*] Diagnosis applicable for this service or product line diagnosisLinkId : positiveInt [0..*] Procedures applicable for this service or product line procedureLinkId : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable for this service or product line informationLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Ruleset Example Revenue Center ?? » Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The date or dates when the enclosed suite of services were performed or completed created serviced[x] : dateTime Type [0..1] date | Period The Insurer who produced this adjudicated response Where the service was provided organization location[x] : Type [0..1] CodeableConcept | Address | Reference [0..1] « Organization ( Location » ); Place where the service is rendered (Strength=Example) Example Service Place ?? The practitioner who number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is responsible a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services rendered delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device Physical service site on the patient (limb, tooth, etc) requestProvider bodySite : CodeableConcept [0..1] The code for the teeth, quadrant, sextant and arch (Strength=Example) Oral Site ?? A region or surface of the site, eg. limb region or tooth surface(s) subSite : CodeableConcept [0..*] The code for the tooth surface and surface combinations (Strength=Example) Surface ?? A billed item may include goods or services provided in multiple encounters encounter : Reference [0..*] Encounter A list of note references to the notes provided below noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : CodeableConcept [1..1] The adjudication codes. (Strength=Example) Adjudication Value ?? Adjudication reason such as limit reached reason : CodeableConcept [0..1] « Practitioner Adjudication reason codes. (Strength=Example) Adjudication Reason » ?? Monitory amount associated with the code amount : Money [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Detail A service line number sequence : positiveInt [1..1] The organization type of product or service type : CodeableConcept [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is responsible a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services rendered delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the patient unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied requestOrganization net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device A list of note references to the notes provided below noteNumber : positiveInt [0..*] SubDetail A service line number sequence : positiveInt [1..1] The type of product or service type : CodeableConcept [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Organization Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center » ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product fee : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItemsDetail The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product fee : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] The type (partial, complete) of the payment (Strength=Example) Example Payment Type ?? Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason ?? Estimated payment date date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifer identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : CodeableConcept [0..1] The presentation types of notes. (Strength=Required) NoteType ! The note text text : string [0..1] 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" for English, or "en-US" for American English versus "en-EN" for England English language : CodeableConcept [0..1] A human language. (Strength=Extensible) Common Languages + BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit, for example MED01, or DENT2 name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : CodeableConcept [0..1] Code to classify in or out of network services (Strength=Example) Network Type ?? Unit designation: individual or family unit : CodeableConcept [0..1] Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : CodeableConcept [0..1] Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? Benefits allowed allowed[x] : Type [0..1] unsignedInt | string | Money Benefits used used[x] : Type [0..1] unsignedInt | Money Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services payee [0..1] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required information [0..*] The members of the team who provided the overall service as well as their role and whether responsible and qualifications careTeam [0..*] Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care insurance [0..1] An accident which resulted in the need for healthcare services accident [0..1] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] Third tier of goods and services subDetail [0..*] Second tier of goods and services detail [0..*] First tier of goods and services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text processNote [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template 

<

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <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 responsible for the EOB --></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 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><!-- 0..1 CodeableConcept organization | patient | practitioner | relatedperson --></resourceType>
  <party><!-- 0..1 Reference(Practitioner|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]><!-- 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..* List of Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey 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>
  <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>
  <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>
  <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 level adjudication details --></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 Language if different from the resource --></adjudication>
   </subDetail>
  </detail>
 </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 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><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence 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 if different from the resource --></language>
 </processNote>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Type of services covered --></category>
  <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></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 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>

JSON Template 

{
  "resourceType" : "",

{doco
  "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 responsible for the EOB
  "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 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
    "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "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 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" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey 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
    "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
    "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
    }],
    "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 level adjudication details
      "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 }] // Language if different from the resource
      }]
    }]
  }],
  "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 }, // 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" : { CodeableConcept }, // 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
    "subCategory" : { CodeableConcept }, // Detailed services covered within the type
    "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 }
    }]
  }]

}

Turtle Template 


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


[ 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 responsible for the EOB
  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 authorizing services or products
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superceded by fulfiller
  fhir:ExplanationOfBenefit.payee [ # 0..1 Party to be paid any benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ CodeableConcept ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:ExplanationOfBenefit.payee.party [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:ExplanationOfBenefit.information.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 General class 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..* List of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the 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.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    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 Explanation of Adjudication outcome
      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 level adjudication details
      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..* Language if different from the resource
      ], ...;
    ], ...;
  ], ...;
  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 Explanation for the non-claim adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.processNote [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Sequence number for this note
    fhir:ExplanationOfBenefit.processNote.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
    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 or services covered
    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.allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since DSTU2

ExplanationOfBenefit
ExplanationOfBenefit.status
  • Added Element
ExplanationOfBenefit.type
  • Added Element
ExplanationOfBenefit.subType
  • Added Element
ExplanationOfBenefit.patient
  • Added Element
ExplanationOfBenefit.billablePeriod
  • Added Element
ExplanationOfBenefit.enterer
  • Added Element
ExplanationOfBenefit.insurer
  • Added Element
ExplanationOfBenefit.provider
  • Added Element
ExplanationOfBenefit.referral
  • Added Element
ExplanationOfBenefit.facility
  • Added Element
ExplanationOfBenefit.claim
  • Added Element
ExplanationOfBenefit.claimResponse
  • Added Element
ExplanationOfBenefit.outcome
  • Type changed from code to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.related
  • Added Element
ExplanationOfBenefit.related.claim
  • Added Element
ExplanationOfBenefit.related.relationship
  • Added Element
ExplanationOfBenefit.related.reference
  • Added Element
ExplanationOfBenefit.prescription
  • Added Element
ExplanationOfBenefit.originalPrescription
  • Added Element
ExplanationOfBenefit.payee
  • Added Element
ExplanationOfBenefit.payee.type
  • Added Element
ExplanationOfBenefit.payee.resourceType
  • Added Element
ExplanationOfBenefit.payee.party
  • Added Element
ExplanationOfBenefit.information
  • Added Element
ExplanationOfBenefit.information.sequence
  • Added Element
ExplanationOfBenefit.information.category
  • Added Element
ExplanationOfBenefit.information.code
  • Added Element
ExplanationOfBenefit.information.timing[x]
  • Added Element
ExplanationOfBenefit.information.value[x]
  • Added Element
ExplanationOfBenefit.information.reason
  • Added Element
ExplanationOfBenefit.careTeam
  • Added Element
ExplanationOfBenefit.careTeam.sequence
  • Added Element
ExplanationOfBenefit.careTeam.provider
  • Added Element
ExplanationOfBenefit.careTeam.responsible
  • Added Element
ExplanationOfBenefit.careTeam.role
  • Added Element
ExplanationOfBenefit.careTeam.qualification
  • Added Element
ExplanationOfBenefit.diagnosis
  • Added Element
ExplanationOfBenefit.diagnosis.sequence
  • Added Element
ExplanationOfBenefit.diagnosis.diagnosis[x]
  • Added Element
ExplanationOfBenefit.diagnosis.type
  • Added Element
ExplanationOfBenefit.diagnosis.packageCode
  • Added Element
ExplanationOfBenefit.procedure
  • Added Element
ExplanationOfBenefit.procedure.sequence
  • Added Element
ExplanationOfBenefit.procedure.date
  • Added Element
ExplanationOfBenefit.procedure.procedure[x]
  • Added Element
ExplanationOfBenefit.precedence
  • Added Element
ExplanationOfBenefit.insurance
  • Added Element
ExplanationOfBenefit.insurance.coverage
  • Added Element
ExplanationOfBenefit.insurance.preAuthRef
  • Added Element
ExplanationOfBenefit.accident
  • Added Element
ExplanationOfBenefit.accident.date
  • Added Element
ExplanationOfBenefit.accident.type
  • Added Element
ExplanationOfBenefit.accident.location[x]
  • Added Element
ExplanationOfBenefit.employmentImpacted
  • Added Element
ExplanationOfBenefit.hospitalization
  • Added Element
ExplanationOfBenefit.item
  • Added Element
ExplanationOfBenefit.item.sequence
  • Added Element
ExplanationOfBenefit.item.careTeamLinkId
  • Added Element
ExplanationOfBenefit.item.diagnosisLinkId
  • Added Element
ExplanationOfBenefit.item.procedureLinkId
  • Added Element
ExplanationOfBenefit.item.informationLinkId
  • Added Element
ExplanationOfBenefit.item.revenue
  • Added Element
ExplanationOfBenefit.item.category
  • Added Element
ExplanationOfBenefit.item.service
  • Added Element
ExplanationOfBenefit.item.modifier
  • Added Element
ExplanationOfBenefit.item.programCode
  • Added Element
ExplanationOfBenefit.item.serviced[x]
  • Added Element
ExplanationOfBenefit.item.location[x]
  • Added Element
ExplanationOfBenefit.item.quantity
  • Added Element
ExplanationOfBenefit.item.unitPrice
  • Added Element
ExplanationOfBenefit.item.factor
  • Added Element
ExplanationOfBenefit.item.net
  • Added Element
ExplanationOfBenefit.item.udi
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Added Element
ExplanationOfBenefit.item.subSite
  • Added Element
ExplanationOfBenefit.item.encounter
  • Added Element
ExplanationOfBenefit.item.noteNumber
  • Added Element
ExplanationOfBenefit.item.adjudication
  • Added Element
ExplanationOfBenefit.item.adjudication.category
  • Added Element
ExplanationOfBenefit.item.adjudication.reason
  • Added Element
ExplanationOfBenefit.item.adjudication.amount
  • Added Element
ExplanationOfBenefit.item.adjudication.value
  • Added Element
ExplanationOfBenefit.item.detail
  • Added Element
ExplanationOfBenefit.item.detail.sequence
  • Added Element
ExplanationOfBenefit.item.detail.type
  • Added Element
ExplanationOfBenefit.item.detail.revenue
  • Added Element
ExplanationOfBenefit.item.detail.category
  • Added Element
ExplanationOfBenefit.item.detail.service
  • Added Element
ExplanationOfBenefit.item.detail.modifier
  • Added Element
ExplanationOfBenefit.item.detail.programCode
  • Added Element
ExplanationOfBenefit.item.detail.quantity
  • Added Element
ExplanationOfBenefit.item.detail.unitPrice
  • Added Element
ExplanationOfBenefit.item.detail.factor
  • Added Element
ExplanationOfBenefit.item.detail.net
  • Added Element
ExplanationOfBenefit.item.detail.udi
  • Added Element
ExplanationOfBenefit.item.detail.noteNumber
  • Added Element
ExplanationOfBenefit.item.detail.adjudication
  • Added Element
ExplanationOfBenefit.item.detail.subDetail
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.sequence
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.type
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.category
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.service
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.modifier
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.programCode
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.quantity
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.unitPrice
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.factor
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.net
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.udi
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.noteNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.adjudication
  • Added Element
ExplanationOfBenefit.addItem
  • Added Element
ExplanationOfBenefit.addItem.sequenceLinkId
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.service
  • Added Element
ExplanationOfBenefit.addItem.modifier
  • Added Element
ExplanationOfBenefit.addItem.fee
  • Added Element
ExplanationOfBenefit.addItem.noteNumber
  • Added Element
ExplanationOfBenefit.addItem.adjudication
  • Added Element
ExplanationOfBenefit.addItem.detail
  • Added Element
ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.category
  • Added Element
ExplanationOfBenefit.addItem.detail.service
  • Added Element
ExplanationOfBenefit.addItem.detail.modifier
  • Added Element
ExplanationOfBenefit.addItem.detail.fee
  • Added Element
ExplanationOfBenefit.addItem.detail.noteNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.adjudication
  • Added Element
ExplanationOfBenefit.totalCost
  • Added Element
ExplanationOfBenefit.unallocDeductable
  • Added Element
ExplanationOfBenefit.totalBenefit
  • Added Element
ExplanationOfBenefit.payment
  • Added Element
ExplanationOfBenefit.payment.type
  • Added Element
ExplanationOfBenefit.payment.adjustment
  • Added Element
ExplanationOfBenefit.payment.adjustmentReason
  • Added Element
ExplanationOfBenefit.payment.date
  • Added Element
ExplanationOfBenefit.payment.amount
  • Added Element
ExplanationOfBenefit.payment.identifier
  • Added Element
ExplanationOfBenefit.form
  • Added Element
ExplanationOfBenefit.processNote
  • Added Element
ExplanationOfBenefit.processNote.number
  • Added Element
ExplanationOfBenefit.processNote.type
  • Added Element
ExplanationOfBenefit.processNote.text
  • Added Element
ExplanationOfBenefit.processNote.language
  • Added Element
ExplanationOfBenefit.benefitBalance
  • Added Element
ExplanationOfBenefit.benefitBalance.category
  • Added Element
ExplanationOfBenefit.benefitBalance.subCategory
  • Added Element
ExplanationOfBenefit.benefitBalance.excluded
  • Added Element
ExplanationOfBenefit.benefitBalance.name
  • Added Element
ExplanationOfBenefit.benefitBalance.description
  • Added Element
ExplanationOfBenefit.benefitBalance.network
  • Added Element
ExplanationOfBenefit.benefitBalance.unit
  • Added Element
ExplanationOfBenefit.benefitBalance.term
  • Added Element
ExplanationOfBenefit.benefitBalance.financial
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.type
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.allowed[x]
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.used[x]
  • Added Element
ExplanationOfBenefit.request
  • deleted
ExplanationOfBenefit.ruleset
  • deleted
ExplanationOfBenefit.originalRuleset
  • deleted
ExplanationOfBenefit.requestProvider
  • deleted
ExplanationOfBenefit.requestOrganization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Σ Remittance Σ Σ Resource version Original version Creation date Insurer Responsible practitioner Responsible organization
Name Flags Card. Type Description & Constraints doco
. . ExplanationOfBenefit DomainResource Explanation of Benefit resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . request . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus ( Required )
... type 0..1 CodeableConcept Type or discipline
Example Claim Type Codes ( Required )
... subType 0..* CodeableConcept Finer grained claim type information
Example Claim SubType Codes ( Example )
... patient 0..1 Reference ( Patient ) The subject of the Products and Services
... billablePeriod 0..1 Period Period for charge submission
... created 0..1 dateTime Creation date
... enterer 0..1 Reference ( Practitioner ) Author
... insurer 0..1 Reference ( Organization ) Insurer responsible for the EOB
... provider 0..1 Reference ( Practitioner ) Responsible provider for the claim
... organization 0..1 Reference ( Organization ) Responsible organization for the claim
... referral 0..1 Reference ( ReferralRequest ) Treatment Referral
... facility 0..1 Reference ( Location ) Servicing Facility
... claim 0..1 Reference ( Claim ) Claim reference
. . outcome . claimResponse Σ 0..1 Reference ( ClaimResponse ) Claim response reference
... outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome Claim Processing Codes ( Required Example )
. . . disposition 0..1 string Disposition Message
. . ruleset . related Σ 0..* BackboneElement Related Claims which may be revelant to processing this claim
.... claim 0..1 Coding Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Ruleset Example Related Claim Relationship Codes ( Example )
. . originalRuleset . . reference Σ 0..1 Identifier Related file or case reference
... prescription 0..1 Reference ( MedicationRequest | VisionPrescription ) Prescription authorizing services or products
... originalPrescription 0..1 Reference ( MedicationRequest ) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Party to be paid any benefits payable
.... type 0..1 CodeableConcept Type of party: Subscriber, Provider, other
Claim Payee Type Codes ( Example )
.... resourceType 0..1 CodeableConcept organization | patient | practitioner | relatedperson
PayeeResourceType ( Required )
.... party 0..1 Reference ( Practitioner | Organization | Patient | RelatedPerson ) Party to receive the payable
... information 0..* BackboneElement Exceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept General class of information
Claim Information Category Codes ( Example )
.... code 0..1 CodeableConcept Type of information
Exception Codes ( Example )
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Additional Data or supporting information
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference ( Any )
.... reason 0..1 Coding Reason associated with the information
Ruleset Missing Tooth Reason Codes ( Example )
. . created . careTeam Σ 0..* BackboneElement Care Team members
.... sequence 1..1 positiveInt Number to covey order of careteam
.... provider 1..1 Reference ( Practitioner | Organization ) Member of the Care Team
.... responsible 0..1 boolean Billing practitioner
.... role 0..1 CodeableConcept Role on the team
Claim Care Team Role Codes ( Example )
.... qualification 0..1 CodeableConcept Type, classification or Specialization
Example Provider Qualification Codes ( Example )
... diagnosis 0..* BackboneElement List of Diagnosis
.... sequence 1..1 positiveInt Number to covey order of diagnosis
.... diagnosis[x] 1..1 Patient's diagnosis
ICD-10 Codes ( Example )
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference ( Condition )
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example )
.... packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
... procedure 0..* BackboneElement Procedures performed
.... sequence 1..1 positiveInt Procedure sequence for reference
.... date 0..1 dateTime When the procedure was performed
. . organization . . procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference ( Procedure )
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance 0..1 BackboneElement Insurance or medical plan
.... coverage 0..1 Reference ( Organization Coverage ) Insurance information
. . requestProvider . . preAuthRef Σ 0..* string Pre-Authorization/Determination Reference
... accident 0..1 BackboneElement Details of an accident
.... date 0..1 date When the accident occurred
.... type 0..1 CodeableConcept The nature of the accident
ActIncidentCode ( Required )
.... location[x] 0..1 Accident Place
..... locationAddress Address
..... locationReference Reference ( Practitioner Location )
. . . employmentImpacted 0..1 Period Period unable to work
. . requestOrganization . hospitalization Σ 0..1 Period Period in hospital
... item 0..* BackboneElement Goods and Services
.... sequence 1..1 positiveInt Service instance
.... careTeamLinkId 0..* positiveInt Applicable careteam members
.... diagnosisLinkId 0..* positiveInt Applicable diagnoses
.... procedureLinkId 0..* positiveInt Applicable procedures
.... informationLinkId 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
.... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
.... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] 0..1 Date or dates of Service
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service
Example Service Place Codes ( Example )
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference ( Organization Location )
. . . . quantity 0..1 SimpleQuantity Count of Products or Services
.... unitPrice 0..1 Money Fee, charge or cost per point
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference ( Device ) Unique Device Identifier
.... bodySite 0..1 CodeableConcept Service Location
Oral Site Codes ( Example )
.... subSite 0..* CodeableConcept Service Sub-location
Surface Codes ( Example )
.... encounter 0..* Reference ( Encounter ) Encounters related to this billed item
.... noteNumber 0..* positiveInt List of note numbers which apply
.... adjudication 0..* BackboneElement Adjudication details
..... category 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes ( Example )
..... reason 0..1 CodeableConcept Explanation of Adjudication outcome
Adjudication Reason Codes ( Example )
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitory value
.... detail 0..* BackboneElement Additional items
..... sequence 1..1 positiveInt Service instance
..... type 1..1 CodeableConcept Group or type of product or service
ActInvoiceGroupCode ( Required )
..... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
..... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
..... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
..... quantity 0..1 SimpleQuantity Count of Products or Services
..... unitPrice 0..1 Money Fee, charge or cost per point
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total additional item cost
..... udi 0..* Reference ( Device ) Unique Device Identifier
..... noteNumber 0..* positiveInt List of note numbers which apply
..... adjudication 0..* see adjudication Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... sequence 1..1 positiveInt Service instance
...... type 1..1 CodeableConcept Type of product or service
ActInvoiceGroupCode ( Required )
...... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
...... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
...... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
...... programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example )
...... quantity 0..1 SimpleQuantity Count of Products or Services
...... unitPrice 0..1 Money Fee, charge or cost per point
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Net additional item cost
...... udi 0..* Reference ( Device ) Unique Device Identifier
...... noteNumber 0..* positiveInt List of note numbers which apply
...... adjudication 0..* see adjudication Language if different from the resource
... addItem 0..* BackboneElement Insurer added line items
.... sequenceLinkId 0..* positiveInt Service instances
.... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
.... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
.... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... fee 0..1 Money Professional fee or Product charge
.... noteNumber 0..* positiveInt List of note numbers which apply
.... adjudication 0..* see adjudication Added items adjudication
.... detail 0..* BackboneElement Added items details
..... revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
..... category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example )
..... service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... fee 0..1 Money Professional fee or Product charge
..... noteNumber 0..* positiveInt List of note numbers which apply
..... adjudication 0..* see adjudication Added items detail adjudication
... totalCost 0..1 Money Total Cost of service from the Claim
... unallocDeductable 0..1 Money Unallocated deductable
... totalBenefit 0..1 Money Total benefit payable for the Claim
... payment 0..1 BackboneElement Payment (if paid)
.... type 0..1 CodeableConcept Partial or Complete
Example Payment Type Codes ( Example )
.... adjustment 0..1 Money Payment adjustment for non-Claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the non-claim adjustment
Payment Adjustment Reason Codes ( Example )
.... date 0..1 date Expected date of Payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Identifier of the payment instrument
... form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Example )
... processNote 0..* BackboneElement Processing notes
. . . . number 0..1 positiveInt Sequence number for this note
.... type 0..1 CodeableConcept display | print | printoper
NoteType ( Required )
.... text 0..1 string Note explanitory text
.... language 0..1 CodeableConcept Language if different from the resource
Common Languages ( Extensible but limited to All Languages )
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
.... subCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Network Type Codes ( Example )
.... unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
.... term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
.... financial 0..* BackboneElement Benefit Summary
..... type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

UML Diagram ( Legend )

ExplanationOfBenefit ( DomainResource ) The Response business identifier EOB Business Identifier identifier : Identifier [0..*] Original request The status of the resource reference instance (this element modifies the meaning of other elements) request status : code [0..1] A code specifying the state of the resource instance. (Strength=Required) ExplanationOfBenefitStatus ! The category of claim, eg, oral, pharmacy, vision, insitutional, professional type : CodeableConcept [0..1] The type or discipline-style of the claim (Strength=Required) Example Claim Type ! A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType subType : CodeableConcept [0..*] A more granulat claim typecode (Strength=Example) Example Claim SubType ?? Patient Resource patient : Reference [0..1] Patient The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the EOB was created created : dateTime [0..1] The person who created the explanation of benefit enterer : Reference [0..1] Practitioner The insurer which is responsible for the explanation of benefit insurer : Reference [0..1] Organization The provider which is responsible for the claim provider : Reference [0..1] Practitioner The provider which is responsible for the claim organization : Reference [0..1] Organization The referral resource which lists the date, practitioner, reason and other supporting information referral : Reference [0..1] ReferralRequest Facility where the services were provided facility : Reference [0..1] Location The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number claim : Reference [0..1] « Claim » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number claimResponse : Reference [0..1] ClaimResponse Transaction status: error, Processing outcome errror, partial or complete processing outcome : code CodeableConcept [0..1] « The outcome result of the processing. (Strength=Required) claim processing (Strength=Example) RemittanceOutcome ! » Claim Processing ?? A description of the status of the adjudication disposition : string [0..1] Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference [0..1] MedicationRequest | VisionPrescription 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 version prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' originalPrescription : Reference [0..1] MedicationRequest Precedence (primary, secondary, etc.) precedence : positiveInt [0..1] The start and optional end dates of when the style patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] The start and optional end dates of resource contents. This should be mapped when the patient was confined to a treatment center hospitalization : Period [0..1] The total cost of the allowable profiles services reported totalCost : Money [0..1] The amount of deductable applied which was not allocated to any particular service line unallocDeductable : Money [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) totalBenefit : Money [0..1] The form to be used for printing the content form : CodeableConcept [0..1] The forms codes. (Strength=Example) Form ?? RelatedClaim Other claims which are related to this and supporting resources claim such as prior claim versions or for related services ruleset claim : Coding Reference [0..1] « Claim For example prior or umbrella relationship : CodeableConcept [0..1] Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... ?? An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, provider, other type : CodeableConcept [0..1] A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? organization | patient | practitioner | relatedperson resourceType : CodeableConcept [0..1] The static type of payee Resource (Strength=Required) PayeeResourceType ! Party to be reimbursed: Subscriber, provider, other party : Reference [0..1] Practitioner | Organization | Patient | RelatedPerson SupportingInformation Sequence of the information element which serves to provide a link sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] The valuset used for additional information category codes. (Strength=Example) Claim Information Category ?? System and dynamic model code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which contents conform, care is sought which may be business version or standard/version. influence the adjudication code : CodeableConcept [0..1] The valuset used for additional information codes. (Strength=Example) Ruleset Exception ?? » The style (standard) date when or period to which this information refers timing[x] : Type [0..1] date | Period Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type [0..1] string | Quantity | Attachment | Reference ( Any ) 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 reason : Coding [0..1] Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? CareTeam Sequence of careteam which serves to order and version provide a link sequence : positiveInt [1..1] The members of the original material team who provided the overall service provider : Reference [1..1] Practitioner | Organization The practitioner who is billing and responsible for the claimed services rendered to the patient responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team role : CodeableConcept [0..1] The role codes for the care team members. (Strength=Example) Claim Care Team Role ?? The qualification which was converted into is applicable for this resource service originalRuleset qualification : Coding CodeableConcept [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? Diagnosis Sequence of diagnosis which serves to provide a link sequence : positiveInt [1..1] The static diagnosis diagnosis[x] : Type [1..1] CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? The type of the Diagnosis, for example: admitting, primary, secondary, discharge type : CodeableConcept [0..*] The type of the diagnosis: admitting, principal, discharge (Strength=Example) Example Diagnosis Type ?? The package billing code, for example DRG, based on the assigned grouping code system packageCode : CodeableConcept [0..1] The DRG codes associated with the diagnosis (Strength=Example) Example Diagnosis Related Gro... ?? Procedure Sequence of procedures which serves to order and dynamic model provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] CodeableConcept | Reference ( Procedure ); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? Insurance Reference to the program or plan identification, underwriter or payor coverage : Reference [0..1] Coverage A list of references from the Insurer to which contents conform, these services pertain preAuthRef : string [0..*] Accident Date of an accident which may be business version these services are addressing date : date [0..1] Type of accident: work, auto, etc type : CodeableConcept [0..1] Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! Where the accident occurred location[x] : Type [0..1] Address | Reference ( Location ) Item A service line number sequence : positiveInt [1..1] Careteam applicable for this service or standard/version. product line careTeamLinkId : positiveInt [0..*] Diagnosis applicable for this service or product line diagnosisLinkId : positiveInt [0..*] Procedures applicable for this service or product line procedureLinkId : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable for this service or product line informationLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Ruleset Example Revenue Center ?? » Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The date or dates when the enclosed suite of services were performed or completed created serviced[x] : dateTime Type [0..1] date | Period The Insurer who produced this adjudicated response Where the service was provided organization location[x] : Type [0..1] CodeableConcept | Address | Reference [0..1] « Organization ( Location » ); Place where the service is rendered (Strength=Example) Example Service Place ?? The practitioner who number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is responsible a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services rendered delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device Physical service site on the patient (limb, tooth, etc) requestProvider bodySite : CodeableConcept [0..1] The code for the teeth, quadrant, sextant and arch (Strength=Example) Oral Site ?? A region or surface of the site, eg. limb region or tooth surface(s) subSite : CodeableConcept [0..*] The code for the tooth surface and surface combinations (Strength=Example) Surface ?? A billed item may include goods or services provided in multiple encounters encounter : Reference [0..*] Encounter A list of note references to the notes provided below noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc category : CodeableConcept [1..1] The adjudication codes. (Strength=Example) Adjudication Value ?? Adjudication reason such as limit reached reason : CodeableConcept [0..1] « Practitioner Adjudication reason codes. (Strength=Example) Adjudication Reason » ?? Monitory amount associated with the code amount : Money [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] Detail A service line number sequence : positiveInt [1..1] The organization type of product or service type : CodeableConcept [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is responsible a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services rendered delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the patient unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied requestOrganization net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device A list of note references to the notes provided below noteNumber : positiveInt [0..*] SubDetail A service line number sequence : positiveInt [1..1] The type of product or service type : CodeableConcept [1..1] Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) ActInvoiceGroupCode ! The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Organization Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center » ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : CodeableConcept [0..*] Program specific reason codes (Strength=Example) Example Program Reason ?? The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] Device A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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' service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product fee : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItemsDetail The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [0..1] Allowable service and product codes (Strength=Example) USCLS ?? Item typification or modifiers codes, eg 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 modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product fee : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] The type (partial, complete) of the payment (Strength=Example) Example Payment Type ?? Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason ?? Estimated payment date date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifer identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : CodeableConcept [0..1] The presentation types of notes. (Strength=Required) NoteType ! The note text text : string [0..1] 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" for English, or "en-US" for American English versus "en-EN" for England English language : CodeableConcept [0..1] A human language. (Strength=Extensible) Common Languages + BenefitBalance Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage excluded : boolean [0..1] A short name or tag for the benefit, for example MED01, or DENT2 name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : CodeableConcept [0..1] Code to classify in or out of network services (Strength=Example) Network Type ?? Unit designation: individual or family unit : CodeableConcept [0..1] Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : CodeableConcept [0..1] Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? Benefits allowed allowed[x] : Type [0..1] unsignedInt | string | Money Benefits used used[x] : Type [0..1] unsignedInt | Money Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services payee [0..1] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required information [0..*] The members of the team who provided the overall service as well as their role and whether responsible and qualifications careTeam [0..*] Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care insurance [0..1] An accident which resulted in the need for healthcare services accident [0..1] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] Third tier of goods and services subDetail [0..*] Second tier of goods and services detail [0..*] First tier of goods and services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text processNote [0..*] Benefits Used to date financial [0..*] Balance by Benefit Category benefitBalance [0..*]

XML Template 

<

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <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 responsible for the EOB --></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 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><!-- 0..1 CodeableConcept organization | patient | practitioner | relatedperson --></resourceType>
  <party><!-- 0..1 Reference(Practitioner|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]><!-- 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..* List of Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey 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>
  <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>
  <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>
  <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 level adjudication details --></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 Language if different from the resource --></adjudication>
   </subDetail>
  </detail>
 </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 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><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence 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 if different from the resource --></language>
 </processNote>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Type of services covered --></category>
  <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></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 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>

JSON Template 

{
  "resourceType" : "",

{doco
  "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 responsible for the EOB
  "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 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
    "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "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 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" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey 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
    "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
    "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
    }],
    "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 level adjudication details
      "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 }] // Language if different from the resource
      }]
    }]
  }],
  "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 }, // 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" : { CodeableConcept }, // 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
    "subCategory" : { CodeableConcept }, // Detailed services covered within the type
    "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 }
    }]
  }]

}

Turtle Template 


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


[ 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 responsible for the EOB
  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 authorizing services or products
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superceded by fulfiller
  fhir:ExplanationOfBenefit.payee [ # 0..1 Party to be paid any benefits payable
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ CodeableConcept ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:ExplanationOfBenefit.payee.party [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:ExplanationOfBenefit.information.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 General class 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..* List of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the 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.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    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 Explanation of Adjudication outcome
      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 level adjudication details
      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..* Language if different from the resource
      ], ...;
    ], ...;
  ], ...;
  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 Explanation for the non-claim adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.processNote [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.processNote.number [ positiveInt ]; # 0..1 Sequence number for this note
    fhir:ExplanationOfBenefit.processNote.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.processNote.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
    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 or services covered
    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.allowed[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ Money ]
    ], ...;
  ], ...;
]

  Changes since DSTU2

ExplanationOfBenefit
ExplanationOfBenefit.status
  • Added Element
ExplanationOfBenefit.type
  • Added Element
ExplanationOfBenefit.subType
  • Added Element
ExplanationOfBenefit.patient
  • Added Element
ExplanationOfBenefit.billablePeriod
  • Added Element
ExplanationOfBenefit.enterer
  • Added Element
ExplanationOfBenefit.insurer
  • Added Element
ExplanationOfBenefit.provider
  • Added Element
ExplanationOfBenefit.referral
  • Added Element
ExplanationOfBenefit.facility
  • Added Element
ExplanationOfBenefit.claim
  • Added Element
ExplanationOfBenefit.claimResponse
  • Added Element
ExplanationOfBenefit.outcome
  • Type changed from code to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.related
  • Added Element
ExplanationOfBenefit.related.claim
  • Added Element
ExplanationOfBenefit.related.relationship
  • Added Element
ExplanationOfBenefit.related.reference
  • Added Element
ExplanationOfBenefit.prescription
  • Added Element
ExplanationOfBenefit.originalPrescription
  • Added Element
ExplanationOfBenefit.payee
  • Added Element
ExplanationOfBenefit.payee.type
  • Added Element
ExplanationOfBenefit.payee.resourceType
  • Added Element
ExplanationOfBenefit.payee.party
  • Added Element
ExplanationOfBenefit.information
  • Added Element
ExplanationOfBenefit.information.sequence
  • Added Element
ExplanationOfBenefit.information.category
  • Added Element
ExplanationOfBenefit.information.code
  • Added Element
ExplanationOfBenefit.information.timing[x]
  • Added Element
ExplanationOfBenefit.information.value[x]
  • Added Element
ExplanationOfBenefit.information.reason
  • Added Element
ExplanationOfBenefit.careTeam
  • Added Element
ExplanationOfBenefit.careTeam.sequence
  • Added Element
ExplanationOfBenefit.careTeam.provider
  • Added Element
ExplanationOfBenefit.careTeam.responsible
  • Added Element
ExplanationOfBenefit.careTeam.role
  • Added Element
ExplanationOfBenefit.careTeam.qualification
  • Added Element
ExplanationOfBenefit.diagnosis
  • Added Element
ExplanationOfBenefit.diagnosis.sequence
  • Added Element
ExplanationOfBenefit.diagnosis.diagnosis[x]
  • Added Element
ExplanationOfBenefit.diagnosis.type
  • Added Element
ExplanationOfBenefit.diagnosis.packageCode
  • Added Element
ExplanationOfBenefit.procedure
  • Added Element
ExplanationOfBenefit.procedure.sequence
  • Added Element
ExplanationOfBenefit.procedure.date
  • Added Element
ExplanationOfBenefit.procedure.procedure[x]
  • Added Element
ExplanationOfBenefit.precedence
  • Added Element
ExplanationOfBenefit.insurance
  • Added Element
ExplanationOfBenefit.insurance.coverage
  • Added Element
ExplanationOfBenefit.insurance.preAuthRef
  • Added Element
ExplanationOfBenefit.accident
  • Added Element
ExplanationOfBenefit.accident.date
  • Added Element
ExplanationOfBenefit.accident.type
  • Added Element
ExplanationOfBenefit.accident.location[x]
  • Added Element
ExplanationOfBenefit.employmentImpacted
  • Added Element
ExplanationOfBenefit.hospitalization
  • Added Element
ExplanationOfBenefit.item
  • Added Element
ExplanationOfBenefit.item.sequence
  • Added Element
ExplanationOfBenefit.item.careTeamLinkId
  • Added Element
ExplanationOfBenefit.item.diagnosisLinkId
  • Added Element
ExplanationOfBenefit.item.procedureLinkId
  • Added Element
ExplanationOfBenefit.item.informationLinkId
  • Added Element
ExplanationOfBenefit.item.revenue
  • Added Element
ExplanationOfBenefit.item.category
  • Added Element
ExplanationOfBenefit.item.service
  • Added Element
ExplanationOfBenefit.item.modifier
  • Added Element
ExplanationOfBenefit.item.programCode
  • Added Element
ExplanationOfBenefit.item.serviced[x]
  • Added Element
ExplanationOfBenefit.item.location[x]
  • Added Element
ExplanationOfBenefit.item.quantity
  • Added Element
ExplanationOfBenefit.item.unitPrice
  • Added Element
ExplanationOfBenefit.item.factor
  • Added Element
ExplanationOfBenefit.item.net
  • Added Element
ExplanationOfBenefit.item.udi
  • Added Element
ExplanationOfBenefit.item.bodySite
  • Added Element
ExplanationOfBenefit.item.subSite
  • Added Element
ExplanationOfBenefit.item.encounter
  • Added Element
ExplanationOfBenefit.item.noteNumber
  • Added Element
ExplanationOfBenefit.item.adjudication
  • Added Element
ExplanationOfBenefit.item.adjudication.category
  • Added Element
ExplanationOfBenefit.item.adjudication.reason
  • Added Element
ExplanationOfBenefit.item.adjudication.amount
  • Added Element
ExplanationOfBenefit.item.adjudication.value
  • Added Element
ExplanationOfBenefit.item.detail
  • Added Element
ExplanationOfBenefit.item.detail.sequence
  • Added Element
ExplanationOfBenefit.item.detail.type
  • Added Element
ExplanationOfBenefit.item.detail.revenue
  • Added Element
ExplanationOfBenefit.item.detail.category
  • Added Element
ExplanationOfBenefit.item.detail.service
  • Added Element
ExplanationOfBenefit.item.detail.modifier
  • Added Element
ExplanationOfBenefit.item.detail.programCode
  • Added Element
ExplanationOfBenefit.item.detail.quantity
  • Added Element
ExplanationOfBenefit.item.detail.unitPrice
  • Added Element
ExplanationOfBenefit.item.detail.factor
  • Added Element
ExplanationOfBenefit.item.detail.net
  • Added Element
ExplanationOfBenefit.item.detail.udi
  • Added Element
ExplanationOfBenefit.item.detail.noteNumber
  • Added Element
ExplanationOfBenefit.item.detail.adjudication
  • Added Element
ExplanationOfBenefit.item.detail.subDetail
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.sequence
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.type
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.revenue
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.category
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.service
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.modifier
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.programCode
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.quantity
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.unitPrice
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.factor
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.net
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.udi
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.noteNumber
  • Added Element
ExplanationOfBenefit.item.detail.subDetail.adjudication
  • Added Element
ExplanationOfBenefit.addItem
  • Added Element
ExplanationOfBenefit.addItem.sequenceLinkId
  • Added Element
ExplanationOfBenefit.addItem.revenue
  • Added Element
ExplanationOfBenefit.addItem.category
  • Added Element
ExplanationOfBenefit.addItem.service
  • Added Element
ExplanationOfBenefit.addItem.modifier
  • Added Element
ExplanationOfBenefit.addItem.fee
  • Added Element
ExplanationOfBenefit.addItem.noteNumber
  • Added Element
ExplanationOfBenefit.addItem.adjudication
  • Added Element
ExplanationOfBenefit.addItem.detail
  • Added Element
ExplanationOfBenefit.addItem.detail.revenue
  • Added Element
ExplanationOfBenefit.addItem.detail.category
  • Added Element
ExplanationOfBenefit.addItem.detail.service
  • Added Element
ExplanationOfBenefit.addItem.detail.modifier
  • Added Element
ExplanationOfBenefit.addItem.detail.fee
  • Added Element
ExplanationOfBenefit.addItem.detail.noteNumber
  • Added Element
ExplanationOfBenefit.addItem.detail.adjudication
  • Added Element
ExplanationOfBenefit.totalCost
  • Added Element
ExplanationOfBenefit.unallocDeductable
  • Added Element
ExplanationOfBenefit.totalBenefit
  • Added Element
ExplanationOfBenefit.payment
  • Added Element
ExplanationOfBenefit.payment.type
  • Added Element
ExplanationOfBenefit.payment.adjustment
  • Added Element
ExplanationOfBenefit.payment.adjustmentReason
  • Added Element
ExplanationOfBenefit.payment.date
  • Added Element
ExplanationOfBenefit.payment.amount
  • Added Element
ExplanationOfBenefit.payment.identifier
  • Added Element
ExplanationOfBenefit.form
  • Added Element
ExplanationOfBenefit.processNote
  • Added Element
ExplanationOfBenefit.processNote.number
  • Added Element
ExplanationOfBenefit.processNote.type
  • Added Element
ExplanationOfBenefit.processNote.text
  • Added Element
ExplanationOfBenefit.processNote.language
  • Added Element
ExplanationOfBenefit.benefitBalance
  • Added Element
ExplanationOfBenefit.benefitBalance.category
  • Added Element
ExplanationOfBenefit.benefitBalance.subCategory
  • Added Element
ExplanationOfBenefit.benefitBalance.excluded
  • Added Element
ExplanationOfBenefit.benefitBalance.name
  • Added Element
ExplanationOfBenefit.benefitBalance.description
  • Added Element
ExplanationOfBenefit.benefitBalance.network
  • Added Element
ExplanationOfBenefit.benefitBalance.unit
  • Added Element
ExplanationOfBenefit.benefitBalance.term
  • Added Element
ExplanationOfBenefit.benefitBalance.financial
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.type
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.allowed[x]
  • Added Element
ExplanationOfBenefit.benefitBalance.financial.used[x]
  • Added Element
ExplanationOfBenefit.request
  • deleted
ExplanationOfBenefit.ruleset
  • deleted
ExplanationOfBenefit.originalRuleset
  • deleted
ExplanationOfBenefit.requestProvider
  • deleted
ExplanationOfBenefit.requestOrganization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

 

Alternate definitions: Schema / Schematron , Resource Profile Master Definition ( XML , JSON ), Questionnaire XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle )

7.6.2.1 13.10.2.1 Terminology Bindings

ExplanationOfBenefit.outcome ExplanationOfBenefit.ruleset
Path Definition Type Reference
ExplanationOfBenefit.status A code specifying the state of the resource instance. Required ExplanationOfBenefitStatus
ExplanationOfBenefit.type The outcome type or discipline-style of the processing. claim Required Example Claim Type Codes
ExplanationOfBenefit.subType A more granulat claim typecode Example Example Claim SubType Codes
ExplanationOfBenefit.outcome The result of the claim processing Example RemittanceOutcome Claim Processing Codes
ExplanationOfBenefit.related.relationship Relationship of this claim to a related Claim Example Example Related Claim Relationship Codes
ExplanationOfBenefit.payee.type A code for the party to be reimbursed. Example Claim Payee Type Codes
ExplanationOfBenefit.payee.resourceType The type of payee Resource Required PayeeResourceType
ExplanationOfBenefit.information.category The valuset used for additional information category codes. Example Claim Information Category Codes
ExplanationOfBenefit.information.code The valuset used for additional information codes. Example Exception Codes
ExplanationOfBenefit.information.reason Reason codes for the missing teeth Example Missing Tooth Reason Codes
ExplanationOfBenefit.careTeam.role The role codes for the care team members. Example Claim Care Team Role Codes
ExplanationOfBenefit.careTeam.qualification Provider professional qualifications Example Example Provider Qualification Codes
ExplanationOfBenefit.diagnosis.diagnosis[x] ICD10 Diagnostic codes Example ICD-10 Codes
ExplanationOfBenefit.diagnosis.type The type of the diagnosis: admitting, principal, discharge Example Example Diagnosis Type Codes
ExplanationOfBenefit.diagnosis.packageCode The DRG codes associated with the diagnosis Example Example Diagnosis Related Group Codes
ExplanationOfBenefit.procedure.procedure[x] ICD10 Procedure codes Example ICD-10 Procedure Codes
ExplanationOfBenefit.accident.type Type of accident: work place, auto, etc. Required ActIncidentCode
ExplanationOfBenefit.item.revenue
ExplanationOfBenefit.originalRuleset ExplanationOfBenefit.item.detail.revenue
ExplanationOfBenefit.item.detail.subDetail.revenue
ExplanationOfBenefit.addItem.revenue
ExplanationOfBenefit.addItem.detail.revenue 		Codes for the revenue or cost centers supplying the service and/or products. Example Example Revenue Center Codes
ExplanationOfBenefit.item.category
ExplanationOfBenefit.item.detail.category
ExplanationOfBenefit.item.detail.subDetail.category
ExplanationOfBenefit.addItem.category
ExplanationOfBenefit.addItem.detail.category
ExplanationOfBenefit.benefitBalance.subCategory 		Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
ExplanationOfBenefit.item.service
ExplanationOfBenefit.item.detail.service
ExplanationOfBenefit.item.detail.subDetail.service
ExplanationOfBenefit.addItem.service
ExplanationOfBenefit.addItem.detail.service 		Allowable service and product codes Example USCLS Codes
ExplanationOfBenefit.item.modifier
ExplanationOfBenefit.item.detail.modifier
ExplanationOfBenefit.item.detail.subDetail.modifier
ExplanationOfBenefit.addItem.modifier
ExplanationOfBenefit.addItem.detail.modifier 		Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example Modifier type Codes
ExplanationOfBenefit.item.programCode
ExplanationOfBenefit.item.detail.programCode
ExplanationOfBenefit.item.detail.subDetail.programCode 		Program specific reason codes Example Example Program Reason Codes
ExplanationOfBenefit.item.location[x] Place where the service is rendered Example Example Service Place Codes
ExplanationOfBenefit.item.bodySite The static code for the teeth, quadrant, sextant and dynamic model arch Example Oral Site Codes
ExplanationOfBenefit.item.subSite The code for the tooth surface and surface combinations Example Surface Codes
ExplanationOfBenefit.item.adjudication.category The adjudication codes. Example Adjudication Value Codes
ExplanationOfBenefit.item.adjudication.reason Adjudication reason codes. Example Adjudication Reason Codes
ExplanationOfBenefit.item.detail.type
ExplanationOfBenefit.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc. Required ActInvoiceGroupCode
ExplanationOfBenefit.payment.type The type (partial, complete) of the payment Example Example Payment Type Codes
ExplanationOfBenefit.payment.adjustmentReason Payment Adjustment reason codes. Example Payment Adjustment Reason Codes
ExplanationOfBenefit.form The forms codes. Example Form Codes
ExplanationOfBenefit.processNote.type The presentation types of notes. Required NoteType
ExplanationOfBenefit.processNote.language A human language. Extensible , but limited to which contents conform, which may be business version All Languages Common Languages
ExplanationOfBenefit.benefitBalance.category Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
ExplanationOfBenefit.benefitBalance.network Code to classify in or standard/version. out of network services Example Ruleset Network Type Codes
ExplanationOfBenefit.benefitBalance.unit Unit covered/serviced - individual or family Example Unit Type Codes
ExplanationOfBenefit.benefitBalance.term Coverage unit - annual, lifetime Example Benefit Term Codes
ExplanationOfBenefit.benefitBalance.financial.type Deductable, visits, co-pay, etc. Example Benefit Type Codes

7.6.3 13.10.3 Search Parameters

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

Name Type Description Paths Expression In Common
care-team reference Member of the CareTeam ExplanationOfBenefit.careTeam.provider
( Practitioner , Organization )
claim reference The reference to the claim ExplanationOfBenefit.claim
( Claim )
coverage reference The plan under which the claim was adjudicated ExplanationOfBenefit.insurance.coverage
( Coverage )
created date The creation date for the EOB ExplanationOfBenefit.created
disposition string The contents of the disposition message ExplanationOfBenefit.disposition
encounter reference Encounters associated with a billed line item ExplanationOfBenefit.item.encounter
( Encounter )
enterer reference The party responsible for the entry of the Claim ExplanationOfBenefit.enterer
( Practitioner )
facility reference Facility responsible for the goods and services ExplanationOfBenefit.facility
( Location )
identifier token The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier
organization reference The reference to the providing organization ExplanationOfBenefit.organization
( Organization )
patient reference The reference to the patient ExplanationOfBenefit.patient
( Patient )
payee reference The party receiving any payment for the Claim ExplanationOfBenefit.payee.party
( Practitioner , Organization , Patient , RelatedPerson )
provider reference The reference to the provider ExplanationOfBenefit.provider
( Practitioner )