http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit|5.0.0

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.
Structure JSON Dependencies FHIRSchema Other Versions Dependant (0)Elements Summary
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: {isModifier: false, short: The recipient of the products and services, mustSupport: false, isSummary: true, index: 6}
  claimResponse: {isModifier: false, short: Claim response reference, mustSupport: false, isSummary: false, index: 32}
  insurance:
    isModifier: false
    short: Patient insurance information
    mustSupport: false
    array: true
    isSummary: true
    index: 68
    elements:
      focal: {isModifier: false, short: Coverage to be used for adjudication, mustSupport: false, isSummary: true, index: 69}
      coverage: {isModifier: false, short: Insurance information, mustSupport: false, isSummary: true, index: 70}
      preAuthRef: {isModifier: false, short: Prior authorization reference number, mustSupport: false, array: true, isSummary: false, index: 71}
    required: [coverage, focal]
  benefitBalance:
    isModifier: false
    short: Balance by Benefit Category
    mustSupport: false
    array: true
    isSummary: false
    index: 233
    elements:
      category:
        isModifier: false
        short: Benefit classification
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 234
      excluded: {isModifier: false, short: Excluded from the plan, mustSupport: false, isSummary: false, index: 235}
      name: {isModifier: false, short: Short name for the benefit, mustSupport: false, isSummary: false, index: 236}
      description: {isModifier: false, short: Description of the benefit or services covered, mustSupport: false, isSummary: false, index: 237}
      network:
        isModifier: false
        short: In or out of network
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-network'}
        isSummary: false
        index: 238
      unit:
        isModifier: false
        short: Individual or family
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        isSummary: false
        index: 239
      term:
        isModifier: false
        short: Annual or lifetime
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        isSummary: false
        index: 240
      financial:
        isModifier: false
        short: Benefit Summary
        mustSupport: false
        array: true
        isSummary: false
        index: 241
        elements:
          type:
            isModifier: false
            short: Benefit classification
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-type'}
            isSummary: false
            index: 242
          allowed:
            isModifier: false
            short: Benefits allowed
            mustSupport: false
            choices: []
            isSummary: false
            index: 244
          used:
            isModifier: false
            short: Benefits used
            mustSupport: false
            choices: []
            isSummary: false
            index: 246
        required: [type]
    required: [category]
  facility: {isModifier: false, short: Servicing Facility, mustSupport: false, isSummary: false, index: 30}
  processNote:
    isModifier: false
    short: Note concerning adjudication
    mustSupport: false
    array: true
    isSummary: false
    index: 227
    elements:
      number: {isModifier: false, short: Note instance identifier, mustSupport: false, isSummary: false, index: 228}
      type:
        isModifier: false
        short: Note purpose
        mustSupport: false
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/note-type'}
        isSummary: false
        index: 229
      text: {isModifier: false, short: Note explanatory text, mustSupport: false, isSummary: false, index: 230}
      language:
        isModifier: false
        short: Language of the text
        mustSupport: false
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/all-languages|5.0.0'}
        isSummary: false
        index: 231
  diagnosis:
    isModifier: false
    short: Pertinent diagnosis information
    mustSupport: false
    array: true
    isSummary: false
    index: 54
    elements:
      sequence: {isModifier: false, short: Diagnosis instance identifier, mustSupport: false, isSummary: false, index: 55}
      diagnosis:
        isModifier: false
        short: Nature of illness or problem
        mustSupport: false
        choices: []
        isSummary: false
        index: 57
      type:
        isModifier: false
        short: Timing or nature of the diagnosis
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        isSummary: false
        index: 58
      onAdmission:
        isModifier: false
        short: Present on admission
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        isSummary: false
        index: 59
    required: [diagnosis, sequence]
  preAuthRef: {isModifier: false, short: Preauthorization reference, mustSupport: false, array: true, isSummary: false, index: 36}
  adjudication:
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
    isModifier: false
    short: Header-level adjudication
    mustSupport: false
    array: true
    isSummary: false
    index: 214
  enterer: {isModifier: false, short: Author of the claim, mustSupport: false, isSummary: false, index: 9}
  supportingInfo:
    isModifier: false
    short: Supporting information
    mustSupport: false
    array: true
    isSummary: false
    index: 45
    elements:
      sequence: {isModifier: false, short: Information instance identifier, mustSupport: false, isSummary: false, index: 46}
      category:
        isModifier: false
        short: Classification of the supplied information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        isSummary: false
        index: 47
      code:
        isModifier: false
        short: Type of information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        isSummary: false
        index: 48
      timing:
        isModifier: false
        short: When it occurred
        mustSupport: false
        choices: []
        isSummary: false
        index: 50
      value:
        isModifier: false
        short: Data to be provided
        mustSupport: false
        choices: []
        isSummary: false
        index: 52
      reason:
        isModifier: false
        short: Explanation for the information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        isSummary: false
        index: 53
    required: [sequence, category]
  encounter: {isModifier: false, short: Encounters associated with the listed treatments, mustSupport: false, array: true, isSummary: false, index: 29}
  use:
    isModifier: false
    short: claim | preauthorization | predetermination
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|5.0.0'}
    isSummary: true
    index: 5
  payment:
    isModifier: false
    short: Payment Details
    mustSupport: false
    isSummary: false
    index: 218
    elements:
      type:
        isModifier: false
        short: Partial or complete payment
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        isSummary: false
        index: 219
      adjustment: {isModifier: false, short: Payment adjustment for non-claim issues, mustSupport: false, isSummary: false, index: 220}
      adjustmentReason:
        isModifier: false
        short: Explanation for the variance
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        isSummary: false
        index: 221
      date: {isModifier: false, short: Expected date of payment, mustSupport: false, isSummary: false, index: 222}
      amount: {isModifier: false, short: Payable amount after adjustment, mustSupport: false, isSummary: false, index: 223}
      identifier: {isModifier: false, short: Business identifier for the payment, mustSupport: false, isSummary: false, index: 224}
  traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 1}
  item:
    isModifier: false
    short: Product or service provided
    mustSupport: false
    array: true
    isSummary: false
    index: 78
    elements:
      category:
        isModifier: false
        short: Benefit classification
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 86
      diagnosisSequence: {isModifier: false, short: Applicable diagnoses, mustSupport: false, array: true, isSummary: false, index: 81}
      procedureSequence: {isModifier: false, short: Applicable procedures, mustSupport: false, array: true, isSummary: false, index: 82}
      request: {isModifier: false, short: Request or Referral for Service, mustSupport: false, array: true, isSummary: false, index: 89}
      modifier:
        isModifier: false
        short: Product or service billing modifiers
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 90
      revenue:
        isModifier: false
        short: Revenue or cost center code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        isSummary: false
        index: 85
      adjudication:
        isModifier: false
        short: Adjudication details
        mustSupport: false
        array: true
        isSummary: false
        index: 113
        elements:
          category:
            isModifier: false
            short: Type of adjudication information
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            isSummary: false
            index: 114
          reason:
            isModifier: false
            short: Explanation of adjudication outcome
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            isSummary: false
            index: 115
          amount: {isModifier: false, short: Monetary amount, mustSupport: false, isSummary: false, index: 116}
          quantity: {isModifier: false, short: Non-monitary value, mustSupport: false, isSummary: false, index: 117}
        required: [category]
      encounter: {isModifier: false, short: Encounters associated with the listed treatments, mustSupport: false, array: true, isSummary: false, index: 106}
      productOrServiceEnd:
        isModifier: false
        short: End of a range of codes
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 88
      traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 84}
      net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 101}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: []
        isSummary: false
        index: 93
      tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 100}
      careTeamSequence: {isModifier: false, short: Applicable care team members, mustSupport: false, array: true, isSummary: false, index: 80}
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 87
      udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 102}
      informationSequence: {isModifier: false, short: Applicable exception and supporting information, mustSupport: false, array: true, isSummary: false, index: 83}
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 91
      factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 99}
      sequence: {isModifier: false, short: Item instance identifier, mustSupport: false, isSummary: false, index: 79}
      bodySite:
        isModifier: false
        short: Anatomical location
        mustSupport: false
        array: true
        isSummary: false
        index: 103
        elements:
          site:
            min: 1
            isModifier: false
            short: Location
            index: 104
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
            isSummary: false
          subSite:
            isModifier: false
            short: Sub-location
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
            isSummary: false
            index: 105
        required: [site]
      quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 97}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: []
        isSummary: false
        index: 95
      noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 107}
      patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 96}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 98}
      reviewOutcome:
        isModifier: false
        short: Adjudication results
        mustSupport: false
        isSummary: false
        index: 108
        elements:
          decision:
            isModifier: false
            short: Result of the adjudication
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision'}
            isSummary: false
            index: 109
          reason:
            isModifier: false
            short: Reason for result of the adjudication
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision-reason'}
            isSummary: false
            index: 110
          preAuthRef: {isModifier: false, short: Preauthorization reference, mustSupport: false, isSummary: false, index: 111}
          preAuthPeriod: {isModifier: false, short: Preauthorization reference effective period, mustSupport: false, isSummary: false, index: 112}
      detail:
        isModifier: false
        short: Additional items
        mustSupport: false
        array: true
        isSummary: false
        index: 118
        elements:
          category:
            isModifier: false
            short: Benefit classification
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            isSummary: false
            index: 122
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 125
          revenue:
            isModifier: false
            short: Revenue or cost center code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            isSummary: false
            index: 121
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            isModifier: false
            short: Detail level adjudication details
            mustSupport: false
            array: true
            isSummary: false
            index: 136
          productOrServiceEnd:
            isModifier: false
            short: End of a range of codes
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 124
          traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 120}
          net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 132}
          tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 131}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 123
          udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 133}
          programCode:
            isModifier: false
            short: Program the product or service is provided under
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            isSummary: false
            index: 126
          factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 130}
          sequence: {isModifier: false, short: Product or service provided, mustSupport: false, isSummary: false, index: 119}
          subDetail:
            isModifier: false
            short: Additional items
            mustSupport: false
            array: true
            isSummary: false
            index: 137
            elements:
              category:
                isModifier: false
                short: Benefit classification
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                isSummary: false
                index: 141
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 144
              revenue:
                isModifier: false
                short: Revenue or cost center code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                isSummary: false
                index: 140
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                isModifier: false
                short: Subdetail level adjudication details
                mustSupport: false
                array: true
                isSummary: false
                index: 155
              productOrServiceEnd:
                isModifier: false
                short: End of a range of codes
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 143
              traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 139}
              net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 151}
              tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 150}
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 142
              udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 152}
              programCode:
                isModifier: false
                short: Program the product or service is provided under
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                isSummary: false
                index: 145
              factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 149}
              sequence: {isModifier: false, short: Product or service provided, mustSupport: false, isSummary: false, index: 138}
              quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 147}
              noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 153}
              patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 146}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 148}
              reviewOutcome:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, reviewOutcome]
                isModifier: false
                short: Subdetail level adjudication results
                mustSupport: false
                isSummary: false
                index: 154
            required: [sequence]
          quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 128}
          noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 134}
          patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 127}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 129}
          reviewOutcome:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, reviewOutcome]
            isModifier: false
            short: Detail level adjudication results
            mustSupport: false
            isSummary: false
            index: 135
        required: [sequence]
    required: [sequence]
  type:
    isModifier: false
    short: Category or discipline
    mustSupport: false
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 3
  created: {isModifier: false, short: Response creation date, mustSupport: false, isSummary: true, index: 8}
  procedure:
    isModifier: false
    short: Clinical procedures performed
    mustSupport: false
    array: true
    isSummary: false
    index: 60
    elements:
      sequence: {isModifier: false, short: Procedure instance identifier, mustSupport: false, isSummary: false, index: 61}
      type:
        isModifier: false
        short: Category of Procedure
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        isSummary: false
        index: 62
      date: {isModifier: false, short: When the procedure was performed, mustSupport: false, isSummary: false, index: 63}
      procedure:
        isModifier: false
        short: Specific clinical procedure
        mustSupport: false
        choices: []
        isSummary: false
        index: 65
      udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 66}
    required: [sequence, procedure]
  outcome:
    isModifier: false
    short: queued | complete | error | partial
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0'}
    isSummary: true
    index: 33
  related:
    isModifier: false
    short: Prior or corollary claims
    mustSupport: false
    array: true
    isSummary: false
    index: 15
    elements:
      claim: {isModifier: false, short: Reference to the related claim, mustSupport: false, isSummary: false, index: 16}
      relationship:
        isModifier: false
        short: How the reference claim is related
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        isSummary: false
        index: 17
      reference: {isModifier: false, short: File or case reference, mustSupport: false, isSummary: false, index: 18}
  disposition: {isModifier: false, short: Disposition Message, mustSupport: false, isSummary: false, index: 35}
  referral: {isModifier: false, short: Treatment Referral, mustSupport: false, isSummary: false, index: 28}
  preAuthRefPeriod: {isModifier: false, short: Preauthorization in-effect period, mustSupport: false, array: true, isSummary: false, index: 37}
  diagnosisRelatedGroup:
    isModifier: false
    short: Package billing code
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
    isSummary: false
    index: 38
  total:
    isModifier: false
    short: Adjudication totals
    mustSupport: false
    array: true
    isSummary: true
    index: 215
    elements:
      category:
        isModifier: false
        short: Type of adjudication information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 216
      amount: {isModifier: false, short: Financial total for the category, mustSupport: false, isSummary: true, index: 217}
    required: [amount, category]
  event:
    isModifier: false
    short: Event information
    mustSupport: false
    array: true
    isSummary: false
    index: 21
    elements:
      type:
        isModifier: false
        short: Specific event
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/datestype'}
        isSummary: false
        index: 22
      when:
        isModifier: false
        short: Occurance date or period
        mustSupport: false
        choices: []
        isSummary: false
        index: 24
    required: [when, type]
  insurer: {isModifier: false, short: Party responsible for reimbursement, mustSupport: false, isSummary: true, index: 10}
  fundsReserve:
    isModifier: false
    short: Funds reserved status
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 14
  priority:
    isModifier: false
    short: Desired processing urgency
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    isSummary: false
    index: 12
  accident:
    isModifier: false
    short: Details of the event
    mustSupport: false
    isSummary: false
    index: 72
    elements:
      date: {isModifier: false, short: When the incident occurred, mustSupport: false, isSummary: false, index: 73}
      type:
        isModifier: false
        short: The nature of the accident
        mustSupport: false
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        isSummary: false
        index: 74
      location:
        isModifier: false
        short: Where the event occurred
        mustSupport: false
        choices: []
        isSummary: false
        index: 76
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/explanationofbenefit-status|5.0.0'}
    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: 2
  payee:
    isModifier: false
    short: Recipient of benefits payable
    mustSupport: false
    isSummary: false
    index: 25
    elements:
      type:
        isModifier: false
        short: Category of recipient
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        isSummary: false
        index: 26
      party: {isModifier: false, short: Recipient reference, mustSupport: false, isSummary: false, index: 27}
  prescription: {isModifier: false, short: Prescription authorizing services or products, mustSupport: false, isSummary: false, index: 19}
  billablePeriod: {isModifier: false, short: Relevant time frame for the claim, mustSupport: false, isSummary: true, index: 7}
  identifier: {isModifier: false, short: Business Identifier for the resource, mustSupport: false, array: true, isSummary: false, index: 0}
  form: {isModifier: false, short: Printed reference or actual form, mustSupport: false, isSummary: false, index: 226}
  subType:
    isModifier: false
    short: More granular claim type
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    isSummary: false
    index: 4
  fundsReserveRequested:
    isModifier: false
    short: For whom to reserve funds
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 13
  benefitPeriod: {isModifier: false, short: When the benefits are applicable, mustSupport: false, isSummary: false, index: 232}
  precedence: {isModifier: false, short: 'Precedence (primary, secondary, etc.)', mustSupport: false, isSummary: false, index: 67}
  formCode:
    isModifier: false
    short: Printed form identifier
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    isSummary: false
    index: 225
  provider: {isModifier: false, short: Party responsible for the claim, mustSupport: false, isSummary: true, index: 11}
  patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 77}
  addItem:
    isModifier: false
    short: Insurer added line items
    mustSupport: false
    array: true
    isSummary: false
    index: 156
    elements:
      request: {isModifier: false, short: Request or Referral for Service, mustSupport: false, array: true, isSummary: false, index: 165}
      modifier:
        isModifier: false
        short: Service/Product billing modifiers
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 166
      revenue:
        isModifier: false
        short: Revenue or cost center code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        isSummary: false
        index: 162
      adjudication:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
        isModifier: false
        short: Added items adjudication
        mustSupport: false
        array: true
        isSummary: false
        index: 183
      productOrServiceEnd:
        isModifier: false
        short: End of a range of codes
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 164
      traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 160}
      itemSequence: {isModifier: false, short: Item sequence number, mustSupport: false, array: true, isSummary: false, index: 157}
      net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 177}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: []
        isSummary: false
        index: 169
      detailSequence: {isModifier: false, short: Detail sequence number, mustSupport: false, array: true, isSummary: false, index: 158}
      tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 176}
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 163
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 167
      factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 175}
      subDetailSequence: {isModifier: false, short: Subdetail sequence number, mustSupport: false, array: true, isSummary: false, index: 159}
      bodySite:
        isModifier: false
        short: Anatomical location
        mustSupport: false
        array: true
        isSummary: false
        index: 178
        elements:
          site:
            min: 1
            isModifier: false
            short: Location
            index: 179
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
            isSummary: false
          subSite:
            isModifier: false
            short: Sub-location
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
            isSummary: false
            index: 180
        required: [site]
      quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 173}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: []
        isSummary: false
        index: 171
      provider: {isModifier: false, short: Authorized providers, mustSupport: false, array: true, isSummary: false, index: 161}
      noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 181}
      patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 172}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 174}
      reviewOutcome:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, reviewOutcome]
        isModifier: false
        short: Additem level adjudication results
        mustSupport: false
        isSummary: false
        index: 182
      detail:
        isModifier: false
        short: Insurer added line items
        mustSupport: false
        array: true
        isSummary: false
        index: 184
        elements:
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 189
          revenue:
            isModifier: false
            short: Revenue or cost center code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            isSummary: false
            index: 186
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            isModifier: false
            short: Added items adjudication
            mustSupport: false
            array: true
            isSummary: false
            index: 198
          productOrServiceEnd:
            isModifier: false
            short: End of a range of codes
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 188
          traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 185}
          net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 195}
          tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 194}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 187
          factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 193}
          subDetail:
            isModifier: false
            short: Insurer added line items
            mustSupport: false
            array: true
            isSummary: false
            index: 199
            elements:
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 204
              revenue:
                isModifier: false
                short: Revenue or cost center code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                isSummary: false
                index: 201
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                isModifier: false
                short: Added items adjudication
                mustSupport: false
                array: true
                isSummary: false
                index: 213
              productOrServiceEnd:
                isModifier: false
                short: End of a range of codes
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 203
              traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 200}
              net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 210}
              tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 209}
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 202
              factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 208}
              quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 206}
              noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 211}
              patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 205}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 207}
              reviewOutcome:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, reviewOutcome]
                isModifier: false
                short: Additem subdetail level adjudication results
                mustSupport: false
                isSummary: false
                index: 212
          quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 191}
          noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 196}
          patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 190}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 192}
          reviewOutcome:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, reviewOutcome]
            isModifier: false
            short: Additem detail level adjudication results
            mustSupport: false
            isSummary: false
            index: 197
  originalPrescription: {isModifier: false, short: Original prescription if superceded by fulfiller, mustSupport: false, isSummary: false, index: 20}
  decision:
    isModifier: false
    short: Result of the adjudication
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision'}
    isSummary: true
    index: 34
  careTeam:
    isModifier: false
    short: Care Team members
    mustSupport: false
    array: true
    isSummary: false
    index: 39
    elements:
      sequence: {isModifier: false, short: Order of care team, mustSupport: false, isSummary: false, index: 40}
      provider: {isModifier: false, short: Practitioner or organization, mustSupport: false, isSummary: false, index: 41}
      responsible: {isModifier: false, short: Indicator of the lead practitioner, mustSupport: false, isSummary: false, index: 42}
      role:
        isModifier: false
        short: Function within the team
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        isSummary: false
        index: 43
      specialty:
        isModifier: false
        short: Practitioner or provider specialization
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        isSummary: false
        index: 44
    required: [provider, sequence]
  claim: {isModifier: false, short: Claim reference, mustSupport: false, isSummary: false, index: 31}
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 5.0.0
required: [created, status, type, patient, use, outcome]