ExplanationOfBenefit
ResourceFinancial · GeneralTrial useMaturity 2
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.
Tested supportFull test results →
- Backends
- PostgreSQLElasticsearch
- Interactions
- CreateReadUpdatePatchDelete
- Search
- 17 of 17 parameters tested
Structure
| Element | Card. | Type | Description |
|---|---|---|---|
identifier | 0..* | Identifier | Business Identifier for the resource |
statusRequired?!Σ | 1..1 | code | active | cancelled | draft | entered-in-errorBinding (required): explanationofbenefit-status |
typeRequiredΣ | 1..1 | CodeableConcept | Category or disciplineBinding (extensible): claim-type |
subType | 0..1 | CodeableConcept | More granular claim typeBinding (example): claim-subtype |
useRequiredΣ | 1..1 | code | claim | preauthorization | predeterminationBinding (required): claim-use |
patientRequiredΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
billablePeriodΣ | 0..1 | Period | Relevant time frame for the claim |
createdRequiredΣ | 1..1 | dateTime | Response creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
insurerRequiredΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
providerRequiredΣ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgencyBinding (example): processpriority |
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve fundsBinding (example): fundsreserve |
fundsReserve | 0..1 | CodeableConcept | Funds reserved statusBinding (example): fundsreserve |
related | 0..* | BackboneElement | Prior or corollary claims |
claim | 0..1 | Reference(Claim) | Reference to the related claim |
relationship | 0..1 | CodeableConcept | How the reference claim is relatedBinding (example): related-claim-relationship |
reference | 0..1 | Identifier | 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originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |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 | Recipient of benefits payable |
type | 0..1 | CodeableConcept | Category of recipientBinding (example): payeetype |
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference |
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral |
facility | 0..1 | Reference(Location) | Servicing Facility |
claim | 0..1 | Reference(Claim) | Claim reference |
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference |
outcomeRequiredΣ | 1..1 | code | queued | complete | error | partialBinding (required): remittance-outcome |
disposition | 0..1 | string | Disposition Message |
preAuthRef | 0..* | string | Preauthorization reference |
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period |
careTeam | 0..* | BackboneElement | Care Team members |
sequenceRequired | 1..1 | positiveInt | Order of care team |
providerRequired | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
responsible | 0..1 | boolean | Indicator of the lead practitioner |
role | 0..1 | CodeableConcept | Function within the teamBinding (example): claim-careteamrole |
qualification | 0..1 | CodeableConcept | Practitioner credential or specializationBinding (example): provider-qualification |
supportingInfo | 0..* | BackboneElement | Supporting information |
sequenceRequired | 1..1 | positiveInt | Information instance identifier |
categoryRequired | 1..1 | CodeableConcept | Classification of the supplied informationBinding (example): claim-informationcategory |
code | 0..1 | CodeableConcept | Type of informationBinding (example): claim-exception |
timing[x] | 0..1 | date | Period | When it occurred |
value[x] | 0..1 | boolean | string | Quantity | Attachment | Reference(Resource) | Data to be provided |
reason | 0..1 | Coding | Explanation for the informationBinding (example): missing-tooth-reason |
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information |
sequenceRequired | 1..1 | positiveInt | Diagnosis instance identifier |
diagnosis[x]Required | 1..1 | CodeableConcept | Reference(Condition) | Nature of illness or problemBinding (example): icd-10 |
type | 0..* | CodeableConcept | Timing or nature of the diagnosisBinding (example): ex-diagnosistype |
onAdmission | 0..1 | CodeableConcept | Present on admissionBinding (example): ex-diagnosis-on-admission |
packageCode | 0..1 | CodeableConcept | Package billing codeBinding (example): ex-diagnosisrelatedgroup |
procedure | 0..* | BackboneElement | Clinical procedures performed |
sequenceRequired | 1..1 | positiveInt | Procedure instance identifier |
type | 0..* | CodeableConcept | Category of ProcedureBinding (example): ex-procedure-type |
date | 0..1 | dateTime | When the procedure was performed |
procedure[x]Required | 1..1 | CodeableConcept | Reference(Procedure) | Specific clinical procedureBinding (example): icd-10-procedures |
udi | 0..* | Reference(Device) | Unique device identifier |
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
insuranceRequiredΣ | 1..* | BackboneElement | Patient insurance information |
focalRequiredΣ | 1..1 | boolean | Coverage to be used for adjudication |
coverageRequiredΣ | 1..1 | Reference(Coverage) | Insurance information |
preAuthRef | 0..* | string | Prior authorization reference number |
accident | 0..1 | BackboneElement | Details of the event |
date | 0..1 | date | When the incident occurred |
type | 0..1 | CodeableConcept | The nature of the accidentBinding (extensible): v3-ActIncidentCode |
location[x] | 0..1 | Address | Reference(Location) | Where the event occurred |
item | 0..* | BackboneElement | Product or service provided |
sequenceRequired | 1..1 | positiveInt | Item instance identifier |
careTeamSequence | 0..* | positiveInt | Applicable care team members |
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses |
procedureSequence | 0..* | positiveInt | Applicable procedures |
informationSequence | 0..* | positiveInt | Applicable exception and supporting information |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Product or service billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
serviced[x] | 0..1 | date | Period | Date or dates of service or product delivery |
location[x] | 0..1 | CodeableConcept | Address | Reference(Location) | Place of service or where product was suppliedBinding (example): service-place |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
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 | Anatomical locationBinding (example): tooth |
subSite | 0..* | CodeableConcept | Anatomical sub-locationBinding (example): surface |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | BackboneElement | Adjudication details |
categoryRequired | 1..1 | CodeableConcept | Type of adjudication informationBinding (example): adjudication |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcomeBinding (example): adjudication-reason |
amount | 0..1 | Money | Monetary amount |
value | 0..1 | decimal | Non-monitary value |
detail | 0..* | BackboneElement | Additional items |
sequenceRequired | 1..1 | positiveInt | Product or service provided |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
udi | 0..* | Reference(Device) | Unique device identifier |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Detail level adjudication details |
subDetail | 0..* | BackboneElement | Additional items |
sequenceRequired | 1..1 | positiveInt | Product or service provided |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
udi | 0..* | Reference(Device) | Unique device identifier |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Subdetail level adjudication details |
addItem | 0..* | BackboneElement | Insurer added line items |
itemSequence | 0..* | positiveInt | Item sequence number |
detailSequence | 0..* | positiveInt | Detail sequence number |
subDetailSequence | 0..* | positiveInt | Subdetail sequence number |
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
serviced[x] | 0..1 | date | Period | Date or dates of service or product delivery |
location[x] | 0..1 | CodeableConcept | Address | Reference(Location) | Place of service or where product was suppliedBinding (example): service-place |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
bodySite | 0..1 | CodeableConcept | Anatomical locationBinding (example): tooth |
subSite | 0..* | CodeableConcept | Anatomical sub-locationBinding (example): surface |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Added items adjudication |
detail | 0..* | BackboneElement | Insurer added line items |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Added items adjudication |
subDetail | 0..* | BackboneElement | Insurer added line items |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
noteNumber | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Added items adjudication |
adjudication | 0..* | Same as ExplanationOfBenefit.item.adjudication | Header-level adjudication |
totalΣ | 0..* | BackboneElement | Adjudication totals |
categoryRequiredΣ | 1..1 | CodeableConcept | Type of adjudication informationBinding (example): adjudication |
amountRequiredΣ | 1..1 | Money | Financial total for the category |
payment | 0..1 | BackboneElement | Payment Details |
type | 0..1 | CodeableConcept | Partial or complete paymentBinding (example): ex-paymenttype |
adjustment | 0..1 | Money | Payment adjustment for non-claim issues |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the varianceBinding (example): payment-adjustment-reason |
date | 0..1 | date | Expected date of payment |
amount | 0..1 | Money | Payable amount after adjustment |
identifier | 0..1 | Identifier | Business identifier for the payment |
formCode | 0..1 | CodeableConcept | Printed form identifierBinding (example): forms |
form | 0..1 | Attachment | Printed reference or actual form |
processNote | 0..* | BackboneElement | Note concerning adjudication |
number | 0..1 | positiveInt | Note instance identifier |
type | 0..1 | code | display | print | printoperBinding (required): note-type |
text | 0..1 | string | Note explanatory text |
language | 0..1 | CodeableConcept | Language of the textBinding (preferred): languages |
benefitPeriod | 0..1 | Period | When the benefits are applicable |
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category |
categoryRequired | 1..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
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 networkBinding (example): benefit-network |
unit | 0..1 | CodeableConcept | Individual or familyBinding (example): benefit-unit |
term | 0..1 | CodeableConcept | Annual or lifetimeBinding (example): benefit-term |
financial | 0..* | BackboneElement | Benefit Summary |
typeRequired | 1..1 | CodeableConcept | Benefit classificationBinding (example): benefit-type |
allowed[x] | 0..1 | unsignedInt | string | Money | Benefits allowed |
used[x] | 0..1 | unsignedInt | Money | Benefits used |
Σ in _summary results · ?! modifier element · 1.. required · inherited elements in grey
Search parameters
Query with GET [base]/ExplanationOfBenefit?[parameter]=[value]. Type decides which modifiers and prefixes apply, see search features.
| Parameter | Type | Description | PG | ES |
|---|---|---|---|---|
care-team | reference | Member of the CareTeam ExplanationOfBenefit.careTeam.provider | ||
claim | reference | The reference to the claim ExplanationOfBenefit.claim | ||
coverage | reference | The plan under which the claim was adjudicated ExplanationOfBenefit.insurance.coverage | ||
created | date | The creation date for the EOB ExplanationOfBenefit.created | ||
detail-udi | reference | UDI associated with a line item detail product or service ExplanationOfBenefit.item.detail.udi | ||
disposition | string | The contents of the disposition message ExplanationOfBenefit.disposition | ||
encounter | reference | Encounters associated with a billed line item ExplanationOfBenefit.item.encounter | ||
enterer | reference | The party responsible for the entry of the Claim ExplanationOfBenefit.enterer | ||
facility | reference | Facility responsible for the goods and services ExplanationOfBenefit.facility | ||
identifier | token | The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier | ||
item-udi | reference | UDI associated with a line item product or service ExplanationOfBenefit.item.udi | ||
patient | reference | The reference to the patient ExplanationOfBenefit.patient | ||
payee | reference | The party receiving any payment for the Claim ExplanationOfBenefit.payee.party | ||
procedure-udi | reference | UDI associated with a procedure ExplanationOfBenefit.procedure.udi | ||
provider | reference | The reference to the provider ExplanationOfBenefit.provider | ||
status | token | Status of the instance ExplanationOfBenefit.status | ||
subdetail-udi | reference | UDI associated with a line item detail subdetail product or service ExplanationOfBenefit.item.detail.subDetail.udi |
PG: PostgreSQL, ES: Elasticsearch. passes its TestScript checks, fails, not tested yet. The author of the resource Logical id of this artifact When the resource version last changed Profiles this resource claims to conform to Security Labels applied to this resource Identifies where the resource comes from Tags applied to this resource Derived from the R4B DefinitionCommon parameters on every resource (8)
_haste-health-authorreference _idtoken _lastUpdateddate _profileuri _securitytoken _sourceuri _tagtoken _typetoken