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StructureDefinitionsExplanationOfBenefit

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.
StructureJSONDependenciesFHIRSchemaOther VersionsDependant (0)ElementsSummary
NameFlagsCardTypeDescription & Constraints
ExplanationOfBenefit
0..*Explanation of Benefit resource
 
identifier
0..*IdentifierBusiness Identifier for the resource
 
traceNumber
0..*IdentifierNumber for tracking
 
status *
?!Σ
1..1codeactive | cancelled | draft | entered-in-error ExplanationOfBenefitStatus (required)
 
type *
Σ
1..1CodeableConceptCategory or discipline ClaimType (extensible)
 
subType
0..1CodeableConceptMore granular claim type ClaimSubType (example)
 
use *
Σ
1..1codeclaim | preauthorization | predetermination Use (required)
 
patient *
Σ
1..1ReferenceThe recipient of the products and services
 
billablePeriod
Σ
0..1PeriodRelevant time frame for the claim
 
created *
Σ
1..1dateTimeResponse creation date
 
enterer
0..1ReferenceAuthor of the claim
 
insurer
Σ
0..1ReferenceParty responsible for reimbursement
 
provider
Σ
0..1ReferenceParty responsible for the claim
 
priority
0..1CodeableConceptDesired processing urgency ProcessPriority (example)
 
fundsReserveRequested
0..1CodeableConceptFor whom to reserve funds FundsReserve (example)
 
fundsReserve
0..1CodeableConceptFunds reserved status FundsReserve (example)
 
related
0..*BackboneElementPrior or corollary claims
 
 
claim
0..1ReferenceReference to the related claim
 
 
relationship
0..1CodeableConceptHow the reference claim is related RelatedClaimRelationship (example)
 
 
reference
0..1IdentifierFile or case reference
 
prescription
0..1ReferencePrescription authorizing services or products
 
originalPrescription
0..1ReferenceOriginal prescription if superceded by fulfiller
 
event
0..*BackboneElementEvent information
 
 
type *
1..1CodeableConceptSpecific event DatesType (example)
 
 
when[x] *
1..1Occurance date or period
 
 
 
whenDateTime *
1..1dateTime
 
 
 
whenPeriod *
1..1Period
 
payee
0..1BackboneElementRecipient of benefits payable
 
 
type
0..1CodeableConceptCategory of recipient PayeeType (example)
 
 
party
0..1ReferenceRecipient reference
 
referral
0..1ReferenceTreatment Referral
 
encounter
0..*ReferenceEncounters associated with the listed treatments
 
facility
0..1ReferenceServicing Facility
 
claim
0..1ReferenceClaim reference
 
claimResponse
0..1ReferenceClaim response reference
 
outcome *
Σ
1..1codequeued | complete | error | partial ClaimOutcome (required)
 
decision
Σ
0..1CodeableConceptResult of the adjudication AdjudicationDecision (example)
 
disposition
0..1stringDisposition Message
 
preAuthRef
0..*stringPreauthorization reference
 
preAuthRefPeriod
0..*PeriodPreauthorization in-effect period
 
diagnosisRelatedGroup
0..1CodeableConceptPackage billing code DiagnosisRelatedGroup (example)
 
careTeam
0..*BackboneElementCare Team members
 
 
sequence *
1..1positiveIntOrder of care team
 
 
provider *
1..1ReferencePractitioner or organization
 
 
responsible
0..1booleanIndicator of the lead practitioner
 
 
role
0..1CodeableConceptFunction within the team CareTeamRole (example)
 
 
specialty
0..1CodeableConceptPractitioner or provider specialization ProviderQualification (example)
 
supportingInfo
0..*BackboneElementSupporting information
 
 
sequence *
1..1positiveIntInformation instance identifier
 
 
category *
1..1CodeableConceptClassification of the supplied information InformationCategory (example)
 
 
code
0..1CodeableConceptType of information InformationCode (example)
 
 
timing[x]
0..1When it occurred
 
 
 
timingDate
0..1date
 
 
 
timingPeriod
0..1Period
 
 
value[x]
0..1Data to be provided
 
 
 
valueBoolean
0..1boolean
 
 
 
valueString
0..1string
 
 
 
valueQuantity
0..1Quantity
 
 
 
valueAttachment
0..1Attachment
 
 
 
valueReference
0..1Reference
 
 
 
valueIdentifier
0..1Identifier
 
 
reason
0..1CodingExplanation for the information MissingReason (example)
 
diagnosis
0..*BackboneElementPertinent diagnosis information
 
 
sequence *
1..1positiveIntDiagnosis instance identifier
 
 
diagnosis[x] *
1..1Nature of illness or problem ICD10 (example)
 
 
 
diagnosisCodeableConcept *
1..1CodeableConcept ICD10 (example)
 
 
 
diagnosisReference *
1..1Reference ICD10 (example)
 
 
type
0..*CodeableConceptTiming or nature of the diagnosis DiagnosisType (example)
 
 
onAdmission
0..1CodeableConceptPresent on admission DiagnosisOnAdmission (example)
 
procedure
0..*BackboneElementClinical procedures performed
 
 
sequence *
1..1positiveIntProcedure instance identifier
 
 
type
0..*CodeableConceptCategory of Procedure ProcedureType (example)
 
 
date
0..1dateTimeWhen the procedure was performed
 
 
procedure[x] *
1..1Specific clinical procedure ICD10_Procedures (example)
 
 
 
procedureCodeableConcept *
1..1CodeableConcept ICD10_Procedures (example)
 
 
 
procedureReference *
1..1Reference ICD10_Procedures (example)
 
 
udi
0..*ReferenceUnique device identifier
 
precedence
0..1positiveIntPrecedence (primary, secondary, etc.)
 
insurance
Σ
0..*BackboneElementPatient insurance information
 
 
focal *
Σ
1..1booleanCoverage to be used for adjudication
 
 
coverage *
Σ
1..1ReferenceInsurance information
 
 
preAuthRef
0..*stringPrior authorization reference number
 
accident
0..1BackboneElementDetails of the event
 
 
date
0..1dateWhen the incident occurred
 
 
type
0..1CodeableConceptThe nature of the accident AccidentType (extensible)
 
 
location[x]
0..1Where the event occurred
 
 
 
locationAddress
0..1Address
 
 
 
locationReference
0..1Reference
 
patientPaid
0..1MoneyPaid by the patient
 
item
0..*BackboneElementProduct or service provided
 
 
sequence *
1..1positiveIntItem instance identifier
 
 
careTeamSequence
0..*positiveIntApplicable care team members
 
 
diagnosisSequence
0..*positiveIntApplicable diagnoses
 
 
procedureSequence
0..*positiveIntApplicable procedures
 
 
informationSequence
0..*positiveIntApplicable exception and supporting information
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
category
0..1CodeableConceptBenefit classification BenefitCategory (example)
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
request
0..*ReferenceRequest or Referral for Service
 
 
modifier
0..*CodeableConceptProduct or service billing modifiers Modifiers (example)
 
 
programCode
0..*CodeableConceptProgram the product or service is provided under ProgramCode (example)
 
 
serviced[x]
0..1Date or dates of service or product delivery
 
 
 
servicedDate
0..1date
 
 
 
servicedPeriod
0..1Period
 
 
location[x]
0..1Place of service or where product was supplied ServicePlace (example)
 
 
 
locationCodeableConcept
0..1CodeableConcept ServicePlace (example)
 
 
 
locationAddress
0..1Address ServicePlace (example)
 
 
 
locationReference
0..1Reference ServicePlace (example)
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
quantity
0..1QuantityCount of products or services
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
factor
0..1decimalPrice scaling factor
 
 
tax
0..1MoneyTotal tax
 
 
net
0..1MoneyTotal item cost
 
 
udi
0..*ReferenceUnique device identifier
 
 
bodySite
0..*BackboneElementAnatomical location
 
 
 
site *
1..*CodeableReferenceLocation OralSites (example)
 
 
 
subSite
0..*CodeableConceptSub-location Surface (example)
 
 
encounter
0..*ReferenceEncounters associated with the listed treatments
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
reviewOutcome
0..1BackboneElementAdjudication results
 
 
 
decision
0..1CodeableConceptResult of the adjudication AdjudicationDecision (example)
 
 
 
reason
0..*CodeableConceptReason for result of the adjudication AdjudicationDecisionReason (example)
 
 
 
preAuthRef
0..1stringPreauthorization reference
 
 
 
preAuthPeriod
0..1PeriodPreauthorization reference effective period
 
 
adjudication
0..*BackboneElementAdjudication details
 
 
 
category *
1..1CodeableConceptType of adjudication information Adjudication (example)
 
 
 
reason
0..1CodeableConceptExplanation of adjudication outcome AdjudicationReason (example)
 
 
 
amount
0..1MoneyMonetary amount
 
 
 
quantity
0..1QuantityNon-monitary value
 
 
detail
0..*BackboneElementAdditional items
 
 
 
sequence *
1..1positiveIntProduct or service provided
 
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
 
category
0..1CodeableConceptBenefit classification BenefitCategory (example)
 
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
programCode
0..*CodeableConceptProgram the product or service is provided under ProgramCode (example)
 
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
tax
0..1MoneyTotal tax
 
 
 
net
0..1MoneyTotal item cost
 
 
 
udi
0..*ReferenceUnique device identifier
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
reviewOutcome
0..1Detail level adjudication results
 
 
 
adjudication
0..*Detail level adjudication details
 
 
 
subDetail
0..*BackboneElementAdditional items
 
 
 
 
sequence *
1..1positiveIntProduct or service provided
 
 
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
 
 
category
0..1CodeableConceptBenefit classification BenefitCategory (example)
 
 
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
 
programCode
0..*CodeableConceptProgram the product or service is provided under ProgramCode (example)
 
 
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
 
tax
0..1MoneyTotal tax
 
 
 
 
net
0..1MoneyTotal item cost
 
 
 
 
udi
0..*ReferenceUnique device identifier
 
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
 
reviewOutcome
0..1Subdetail level adjudication results
 
 
 
 
adjudication
0..*Subdetail level adjudication details
 
addItem
0..*BackboneElementInsurer added line items
 
 
itemSequence
0..*positiveIntItem sequence number
 
 
detailSequence
0..*positiveIntDetail sequence number
 
 
subDetailSequence
0..*positiveIntSubdetail sequence number
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
provider
0..*ReferenceAuthorized providers
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
request
0..*ReferenceRequest or Referral for Service
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
programCode
0..*CodeableConceptProgram the product or service is provided under ProgramCode (example)
 
 
serviced[x]
0..1Date or dates of service or product delivery
 
 
 
servicedDate
0..1date
 
 
 
servicedPeriod
0..1Period
 
 
location[x]
0..1Place of service or where product was supplied ServicePlace (example)
 
 
 
locationCodeableConcept
0..1CodeableConcept ServicePlace (example)
 
 
 
locationAddress
0..1Address ServicePlace (example)
 
 
 
locationReference
0..1Reference ServicePlace (example)
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
quantity
0..1QuantityCount of products or services
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
factor
0..1decimalPrice scaling factor
 
 
tax
0..1MoneyTotal tax
 
 
net
0..1MoneyTotal item cost
 
 
bodySite
0..*BackboneElementAnatomical location
 
 
 
site *
1..*CodeableReferenceLocation OralSites (example)
 
 
 
subSite
0..*CodeableConceptSub-location Surface (example)
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
reviewOutcome
0..1Additem level adjudication results
 
 
adjudication
0..*Added items adjudication
 
 
detail
0..*BackboneElementInsurer added line items
 
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
tax
0..1MoneyTotal tax
 
 
 
net
0..1MoneyTotal item cost
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
reviewOutcome
0..1Additem detail level adjudication results
 
 
 
adjudication
0..*Added items adjudication
 
 
 
subDetail
0..*BackboneElementInsurer added line items
 
 
 
 
traceNumber
0..*IdentifierNumber for tracking
 
 
 
 
revenue
0..1CodeableConceptRevenue or cost center code RevenueCenter (example)
 
 
 
 
productOrService
0..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
 
productOrServiceEnd
0..1CodeableConceptEnd of a range of codes ServiceProduct (example)
 
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
 
patientPaid
0..1MoneyPaid by the patient
 
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
 
tax
0..1MoneyTotal tax
 
 
 
 
net
0..1MoneyTotal item cost
 
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
 
reviewOutcome
0..1Additem subdetail level adjudication results
 
 
 
 
adjudication
0..*Added items adjudication
 
adjudication
0..*Header-level adjudication
 
total
Σ
0..*BackboneElementAdjudication totals
 
 
category *
Σ
1..1CodeableConceptType of adjudication information Adjudication (example)
 
 
amount *
Σ
1..1MoneyFinancial total for the category
 
payment
0..1BackboneElementPayment Details
 
 
type
0..1CodeableConceptPartial or complete payment PaymentType (example)
 
 
adjustment
0..1MoneyPayment adjustment for non-claim issues
 
 
adjustmentReason
0..1CodeableConceptExplanation for the variance PaymentAdjustmentReason (example)
 
 
date
0..1dateExpected date of payment
 
 
amount
0..1MoneyPayable amount after adjustment
 
 
identifier
0..1IdentifierBusiness identifier for the payment
 
formCode
0..1CodeableConceptPrinted form identifier Forms (example)
 
form
0..1AttachmentPrinted reference or actual form
 
processNote
0..*BackboneElementNote concerning adjudication
 
 
number
0..1positiveIntNote instance identifier
 
 
type
0..1CodeableConceptNote purpose NoteType (extensible)
 
 
text
0..1stringNote explanatory text
 
 
language
0..1CodeableConceptLanguage of the text Language (required)
 
benefitPeriod
0..1PeriodWhen the benefits are applicable
 
benefitBalance
0..*BackboneElementBalance by Benefit Category
 
 
category *
1..1CodeableConceptBenefit classification BenefitCategory (example)
 
 
excluded
0..1booleanExcluded from the plan
 
 
name
0..1stringShort name for the benefit
 
 
description
0..1stringDescription of the benefit or services covered
 
 
network
0..1CodeableConceptIn or out of network BenefitNetwork (example)
 
 
unit
0..1CodeableConceptIndividual or family BenefitUnit (example)
 
 
term
0..1CodeableConceptAnnual or lifetime BenefitTerm (example)
 
 
financial
0..*BackboneElementBenefit Summary
 
 
 
type *
1..1CodeableConceptBenefit classification BenefitType (example)
 
 
 
allowed[x]
0..1Benefits allowed
 
 
 
 
allowedUnsignedInt
0..1unsignedInt
 
 
 
 
allowedString
0..1string
 
 
 
 
allowedMoney
0..1Money
 
 
 
used[x]
0..1Benefits used
 
 
 
 
usedUnsignedInt
0..1unsignedInt
 
 
 
 
usedMoney
0..1Money