This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2 Content Examples Detailed Descriptions Mappings Profiles 7.6 Resource ExplanationOfBenefit - Content This resource maintained by the Financial Management Work Group 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 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 coverage in respect of that Claim. This is the logical combination of the Claim, Claim Response 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 Resource Content Structure UML XML JSON All Structure Name Flags Card. Type Description & Constraints ExplanationOfBenefit DomainResource Remittance resource identifier 0..* Identifier Business Identifier request 0..1 Claim Claim reference outcome 0..1 code complete | error RemittanceOutcome ( Required ) disposition 0..1 string Disposition Message ruleset 0..1 Coding Resource version Ruleset ( Example ) originalRuleset 0..1 Coding Original version Ruleset ( Example ) created 0..1 dateTime Creation date organization 0..1 Organization Insurer requestProvider 0..1 Practitioner Responsible practitioner requestOrganization 0..1 Organization Responsible organization UML Diagram ExplanationOfBenefit ( DomainResource ) The Response Business Identifier identifier : Identifier 0..* Original request resource reference request : Reference ( Claim ) 0..1 Transaction status: error, complete outcome : code 0..1 « The outcome of the processing. RemittanceOutcome » A description of the status of the adjudication disposition : string 0..1 The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 The Insurer who produced this adjudicated response organization : Reference ( Organization ) 0..1 The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( Practitioner ) 0..1 The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( Organization ) 0..1 XML Template < <!-- from --> <!-- from --> <</identifier> <</request> < < <</ruleset> <</originalRuleset> < <</organization> <</requestProvider> <</requestOrganization> </ExplanationOfBenefit> JSON Template { "resourceType" : "", // from // from " " " " " " " " " " } Structure Name Flags Card. Type Description & Constraints ExplanationOfBenefit DomainResource Remittance resource identifier 0..* Identifier Business Identifier request 0..1 Claim Claim reference outcome 0..1 code complete | error RemittanceOutcome ( Required ) disposition 0..1 string Disposition Message ruleset 0..1 Coding Resource version Ruleset ( Example ) originalRuleset 0..1 Coding Original version Ruleset ( Example ) created 0..1 dateTime Creation date organization 0..1 Organization Insurer requestProvider 0..1 Practitioner Responsible practitioner requestOrganization 0..1 Organization Responsible organization UML Diagram ExplanationOfBenefit ( DomainResource ) The Response Business Identifier identifier : Identifier 0..* Original request resource reference request : Reference ( Claim ) 0..1 Transaction status: error, complete outcome : code 0..1 « The outcome of the processing. RemittanceOutcome » A description of the status of the adjudication disposition : string 0..1 The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 The Insurer who produced this adjudicated response organization : Reference ( Organization ) 0..1 The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( Practitioner ) 0..1 The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( Organization ) 0..1 XML Template < <!-- from --> <!-- from --> <</identifier> <</request> < < <</ruleset> <</originalRuleset> < <</organization> <</requestProvider> <</requestOrganization> </ExplanationOfBenefit> JSON Template { "resourceType" : "", // from // from " " " " " " " " " " }   Alternate definitions: Schema / Schematron , Resource Profile ( XML , JSON ), Questionnaire 7.6.2.1 Terminology Bindings Path Definition Type Reference ExplanationOfBenefit.outcome The outcome of the processing. Required http://hl7.org/fhir/RS-link ExplanationOfBenefit.ruleset ExplanationOfBenefit.originalRuleset The static and dynamic model to which contents conform, may be business version or standard and version. Example http://hl7.org/fhir/vs/ruleset 7.6.3 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 identifier token The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier © HL7.org 2011+. FHIR DSTU (v0.4.0-4902) generated on Fri, Mar 27, 2015 00:20+1100. 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