http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit|4.0.1

description: '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.'
derivation: specialization
name: ExplanationOfBenefit
type: ExplanationOfBenefit
elements:
  patient: {short: The recipient of the products and services, isSummary: true, index: 5}
  claimResponse: {short: Claim response reference, index: 26}
  insurance:
    min: 1
    short: Patient insurance information
    array: true
    isSummary: true
    index: 61
    elements:
      focal: {short: Coverage to be used for adjudication, isSummary: true, index: 62}
      coverage: {short: Insurance information, isSummary: true, index: 63}
      preAuthRef: {short: Prior authorization reference number, array: true, index: 64}
    required: [coverage, focal]
  benefitBalance:
    short: Balance by Benefit Category
    array: true
    index: 184
    elements:
      category:
        short: Benefit classification
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        index: 185
      excluded: {short: Excluded from the plan, index: 186}
      name: {short: Short name for the benefit, index: 187}
      description: {short: Description of the benefit or services covered, index: 188}
      network:
        short: In or out of network
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-network'}
        index: 189
      unit:
        short: Individual or family
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        index: 190
      term:
        short: Annual or lifetime
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        index: 191
      financial:
        short: Benefit Summary
        array: true
        index: 192
        elements:
          type:
            short: Benefit classification
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-type'}
            index: 193
          allowed:
            short: Benefits allowed
            choices: []
            index: 195
          used:
            short: Benefits used
            choices: []
            index: 197
        required: [type]
    required: [category]
  facility: {short: Servicing Facility, index: 24}
  processNote:
    short: Note concerning adjudication
    array: true
    index: 178
    elements:
      number: {short: Note instance identifier, index: 179}
      type:
        short: display | print | printoper
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type|4.0.1'}
        index: 180
      text: {short: Note explanatory text, index: 181}
      language:
        short: Language of the text
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'}
        index: 182
  diagnosis:
    short: Pertinent diagnosis information
    array: true
    index: 46
    elements:
      sequence: {short: Diagnosis instance identifier, index: 47}
      diagnosis:
        short: Nature of illness or problem
        choices: []
        index: 49
      type:
        short: Timing or nature of the diagnosis
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        index: 50
      onAdmission:
        short: Present on admission
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        index: 51
      packageCode:
        short: Package billing code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
        index: 52
    required: [diagnosis, sequence]
  preAuthRef: {short: Preauthorization reference, array: true, index: 29}
  adjudication:
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
    short: Header-level adjudication
    array: true
    index: 165
  enterer: {short: Author of the claim, index: 8}
  supportingInfo:
    short: Supporting information
    array: true
    index: 37
    elements:
      sequence: {short: Information instance identifier, index: 38}
      category:
        short: Classification of the supplied information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        index: 39
      code:
        short: Type of information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        index: 40
      timing:
        short: When it occurred
        choices: []
        index: 42
      value:
        short: Data to be provided
        choices: []
        index: 44
      reason:
        short: Explanation for the information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        index: 45
    required: [sequence, category]
  use:
    short: claim | preauthorization | predetermination
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    isSummary: true
    index: 4
  payment:
    short: Payment Details
    index: 169
    elements:
      type:
        short: Partial or complete payment
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        index: 170
      adjustment: {short: Payment adjustment for non-claim issues, index: 171}
      adjustmentReason:
        short: Explanation for the variance
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        index: 172
      date: {short: Expected date of payment, index: 173}
      amount: {short: Payable amount after adjustment, index: 174}
      identifier: {short: Business identifier for the payment, index: 175}
  item:
    short: Product or service provided
    array: true
    index: 70
    elements:
      category:
        short: Benefit classification
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        index: 77
      diagnosisSequence: {short: Applicable diagnoses, array: true, index: 73}
      procedureSequence: {short: Applicable procedures, array: true, index: 74}
      modifier:
        short: Product or service billing modifiers
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 79
      revenue:
        short: Revenue or cost center code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        index: 76
      adjudication:
        short: Adjudication details
        array: true
        index: 94
        elements:
          category:
            short: Type of adjudication information
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            index: 95
          reason:
            short: Explanation of adjudication outcome
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            index: 96
          amount: {short: Monetary amount, index: 97}
          value: {short: Non-monitary value, index: 98}
        required: [category]
      encounter: {short: Encounters related to this billed item, array: true, index: 92}
      net: {short: Total item cost, index: 88}
      serviced:
        short: Date or dates of service or product delivery
        choices: []
        index: 82
      subSite:
        short: Anatomical sub-location
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 91
      careTeamSequence: {short: Applicable care team members, array: true, index: 72}
      productOrService:
        short: Billing, service, product, or drug code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 78
      udi: {short: Unique device identifier, array: true, index: 89}
      informationSequence: {short: Applicable exception and supporting information, array: true, index: 75}
      programCode:
        short: Program the product or service is provided under
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 80
      factor: {short: Price scaling factor, index: 87}
      sequence: {short: Item instance identifier, index: 71}
      bodySite:
        short: Anatomical location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 90
      quantity: {short: Count of products or services, index: 85}
      location:
        short: Place of service or where product was supplied
        choices: []
        index: 84
      noteNumber: {short: Applicable note numbers, array: true, index: 93}
      unitPrice: {short: 'Fee, charge or cost per item', index: 86}
      detail:
        short: Additional items
        array: true
        index: 99
        elements:
          category:
            short: Benefit classification
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            index: 102
          modifier:
            short: Service/Product billing modifiers
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 104
          revenue:
            short: Revenue or cost center code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            index: 101
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            short: Detail level adjudication details
            array: true
            index: 112
          net: {short: Total item cost, index: 109}
          productOrService:
            short: Billing, service, product, or drug code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 103
          udi: {short: Unique device identifier, array: true, index: 110}
          programCode:
            short: Program the product or service is provided under
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            index: 105
          factor: {short: Price scaling factor, index: 108}
          sequence: {short: Product or service provided, index: 100}
          subDetail:
            short: Additional items
            array: true
            index: 113
            elements:
              category:
                short: Benefit classification
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                index: 116
              modifier:
                short: Service/Product billing modifiers
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 118
              revenue:
                short: Revenue or cost center code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                index: 115
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                short: Subdetail level adjudication details
                array: true
                index: 126
              net: {short: Total item cost, index: 123}
              productOrService:
                short: Billing, service, product, or drug code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 117
              udi: {short: Unique device identifier, array: true, index: 124}
              programCode:
                short: Program the product or service is provided under
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                index: 119
              factor: {short: Price scaling factor, index: 122}
              sequence: {short: Product or service provided, index: 114}
              quantity: {short: Count of products or services, index: 120}
              noteNumber: {short: Applicable note numbers, array: true, index: 125}
              unitPrice: {short: 'Fee, charge or cost per item', index: 121}
            required: [sequence, productOrService]
          quantity: {short: Count of products or services, index: 106}
          noteNumber: {short: Applicable note numbers, array: true, index: 111}
          unitPrice: {short: 'Fee, charge or cost per item', index: 107}
        required: [sequence, productOrService]
    required: [sequence, productOrService]
  type:
    short: Category or discipline
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {short: Response creation date, isSummary: true, index: 7}
  procedure:
    short: Clinical procedures performed
    array: true
    index: 53
    elements:
      sequence: {short: Procedure instance identifier, index: 54}
      type:
        short: Category of Procedure
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        index: 55
      date: {short: When the procedure was performed, index: 56}
      procedure:
        short: Specific clinical procedure
        choices: []
        index: 58
      udi: {short: Unique device identifier, array: true, index: 59}
    required: [sequence, procedure]
  outcome:
    short: queued | complete | error | partial
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1'}
    isSummary: true
    index: 27
  related:
    short: Prior or corollary claims
    array: true
    index: 14
    elements:
      claim: {short: Reference to the related claim, index: 15}
      relationship:
        short: How the reference claim is related
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        index: 16
      reference: {short: File or case reference, index: 17}
  disposition: {short: Disposition Message, index: 28}
  referral: {short: Treatment Referral, index: 23}
  preAuthRefPeriod: {short: Preauthorization in-effect period, array: true, index: 30}
  total:
    short: Adjudication totals
    array: true
    isSummary: true
    index: 166
    elements:
      category:
        short: Type of adjudication information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 167
      amount: {short: Financial total for the category, isSummary: true, index: 168}
    required: [amount, category]
  insurer: {short: Party responsible for reimbursement, isSummary: true, index: 9}
  fundsReserve:
    short: Funds reserved status
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 13
  priority:
    short: Desired processing urgency
    binding: {strength: example, valueSet: 'http://terminology.hl7.org/CodeSystem/processpriority'}
    index: 11
  accident:
    short: Details of the event
    index: 65
    elements:
      date: {short: When the incident occurred, index: 66}
      type:
        short: The nature of the accident
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        index: 67
      location:
        short: Where the event occurred
        choices: []
        index: 69
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1'}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 1
  payee:
    short: Recipient of benefits payable
    index: 20
    elements:
      type:
        short: Category of recipient
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        index: 21
      party: {short: Recipient reference, index: 22}
  prescription: {short: Prescription authorizing services or products, index: 18}
  billablePeriod: {short: Relevant time frame for the claim, isSummary: true, index: 6}
  identifier: {short: Business Identifier for the resource, array: true, index: 0}
  form: {short: Printed reference or actual form, index: 177}
  subType:
    short: More granular claim type
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  fundsReserveRequested:
    short: For whom to reserve funds
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 12
  benefitPeriod: {short: When the benefits are applicable, index: 183}
  precedence: {short: 'Precedence (primary, secondary, etc.)', index: 60}
  formCode:
    short: Printed form identifier
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    index: 176
  provider: {short: Party responsible for the claim, isSummary: true, index: 10}
  addItem:
    short: Insurer added line items
    array: true
    index: 127
    elements:
      modifier:
        short: Service/Product billing modifiers
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 133
      adjudication:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
        short: Added items adjudication
        array: true
        index: 146
      itemSequence: {short: Item sequence number, array: true, index: 128}
      net: {short: Total item cost, index: 142}
      serviced:
        short: Date or dates of service or product delivery
        choices: []
        index: 136
      detailSequence: {short: Detail sequence number, array: true, index: 129}
      subSite:
        short: Anatomical sub-location
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 144
      productOrService:
        short: Billing, service, product, or drug code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 132
      programCode:
        short: Program the product or service is provided under
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 134
      factor: {short: Price scaling factor, index: 141}
      subDetailSequence: {short: Subdetail sequence number, array: true, index: 130}
      bodySite:
        short: Anatomical location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 143
      quantity: {short: Count of products or services, index: 139}
      location:
        short: Place of service or where product was supplied
        choices: []
        index: 138
      provider: {short: Authorized providers, array: true, index: 131}
      noteNumber: {short: Applicable note numbers, array: true, index: 145}
      unitPrice: {short: 'Fee, charge or cost per item', index: 140}
      detail:
        short: Insurer added line items
        array: true
        index: 147
        elements:
          modifier:
            short: Service/Product billing modifiers
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 149
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            short: Added items adjudication
            array: true
            index: 155
          net: {short: Total item cost, index: 153}
          productOrService:
            short: Billing, service, product, or drug code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 148
          factor: {short: Price scaling factor, index: 152}
          subDetail:
            short: Insurer added line items
            array: true
            index: 156
            elements:
              productOrService:
                short: Billing, service, product, or drug code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 157
              modifier:
                short: Service/Product billing modifiers
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 158
              quantity: {short: Count of products or services, index: 159}
              unitPrice: {short: 'Fee, charge or cost per item', index: 160}
              factor: {short: Price scaling factor, index: 161}
              net: {short: Total item cost, index: 162}
              noteNumber: {short: Applicable note numbers, array: true, index: 163}
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                short: Added items adjudication
                array: true
                index: 164
            required: [productOrService]
          quantity: {short: Count of products or services, index: 150}
          noteNumber: {short: Applicable note numbers, array: true, index: 154}
          unitPrice: {short: 'Fee, charge or cost per item', index: 151}
        required: [productOrService]
    required: [productOrService]
  originalPrescription: {short: Original prescription if superceded by fulfiller, index: 19}
  careTeam:
    short: Care Team members
    array: true
    index: 31
    elements:
      sequence: {short: Order of care team, index: 32}
      provider: {short: Practitioner or organization, index: 33}
      responsible: {short: Indicator of the lead practitioner, index: 34}
      role:
        short: Function within the team
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        index: 35
      qualification:
        short: Practitioner credential or specialization
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        index: 36
    required: [provider, sequence]
  claim: {short: Claim reference, index: 25}
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [created, insurer, provider, status, insurance, type, patient, use, outcome]