ExplanationOfBenefit
FinancialThis 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.
| Path | Card. | Type | Description & Constraints |
|---|---|---|---|
| ExplanationOfBenefit | 0..* | — | Explanation of Benefit resource |
| .idΣ | 0..1 | String | Logical id of this artifact |
| .metaΣ | 0..1 | Meta | Metadata about the resource |
| .implicitRules?!Σ | 0..1 | uri | A set of rules under which this content was created |
| .language | 0..1 | code | Language of the resource content Bindinglanguages(preferred) |
| .text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| .contained | 0..* | Resource | Contained, inline Resources |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?! | 0..* | Extension | Extensions that cannot be ignored |
| .identifier | 0..* | Identifier | Business Identifier for the resource |
| .status?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Bindingexplanationofbenefit-status(required) |
| .typeΣ | 1..1 | CodeableConcept | Category or discipline Bindingclaim-type(extensible) |
| .subType | 0..1 | CodeableConcept | More granular claim type Bindingclaim-subtype(example) |
| .useΣ | 1..1 | code | claim | preauthorization | predetermination Bindingclaim-use(required) |
| .patientΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
| .billablePeriodΣ | 0..1 | Period | Relevant time frame for the claim |
| .createdΣ | 1..1 | dateTime | Response creation date |
| .enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| .insurerΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| .providerΣ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| .priority | 0..1 | CodeableConcept | Desired processing urgency Bindingprocesspriority(example) |
| .fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Bindingfundsreserve(example) |
| .fundsReserve | 0..1 | CodeableConcept | Funds reserved status Bindingfundsreserve(example) |
| .related | 0..* | BackboneElement | Prior or corollary claims |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .claim | 0..1 | Reference(Claim) | Reference to the related claim |
| .relationship | 0..1 | CodeableConcept | How the reference claim is related Bindingrelated-claim-relationship(example) |
| .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 |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .type | 0..1 | CodeableConcept | Category of recipient Bindingpayeetype(example) |
| .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 |
| .outcomeΣ | 1..1 | code | queued | complete | error | partial Bindingremittance-outcome(required) |
| .disposition | 0..1 | string | Disposition Message |
| .preAuthRef | 0..* | string | Preauthorization reference |
| .preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period |
| .careTeam | 0..* | BackboneElement | Care Team members |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Order of care team |
| .provider | 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 team Bindingclaim-careteamrole(example) |
| .qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Bindingprovider-qualification(example) |
| .supportingInfo | 0..* | BackboneElement | Supporting information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Information instance identifier |
| .category | 1..1 | CodeableConcept | Classification of the supplied information Bindingclaim-informationcategory(example) |
| .code | 0..1 | CodeableConcept | Type of information Bindingclaim-exception(example) |
| .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 information Bindingmissing-tooth-reason(example) |
| .diagnosis | 0..* | BackboneElement | Pertinent diagnosis information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Diagnosis instance identifier |
| .diagnosis[x] | 1..1 | CodeableConcept | Reference(Condition) | Nature of illness or problem Bindingicd-10(example) |
| .type | 0..* | CodeableConcept | Timing or nature of the diagnosis Bindingex-diagnosistype(example) |
| .onAdmission | 0..1 | CodeableConcept | Present on admission Bindingex-diagnosis-on-admission(example) |
| .packageCode | 0..1 | CodeableConcept | Package billing code Bindingex-diagnosisrelatedgroup(example) |
| .procedure | 0..* | BackboneElement | Clinical procedures performed |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Procedure instance identifier |
| .type | 0..* | CodeableConcept | Category of Procedure Bindingex-procedure-type(example) |
| .date | 0..1 | dateTime | When the procedure was performed |
| .procedure[x] | 1..1 | CodeableConcept | Reference(Procedure) | Specific clinical procedure Bindingicd-10-procedures(example) |
| .udi | 0..* | Reference(Device) | Unique device identifier |
| .precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| .insuranceΣ | 1..* | BackboneElement | Patient insurance information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .focalΣ | 1..1 | boolean | Coverage to be used for adjudication |
| .coverageΣ | 1..1 | Reference(Coverage) | Insurance information |
| .preAuthRef | 0..* | string | Prior authorization reference number |
| .accident | 0..1 | BackboneElement | Details of the event |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .date | 0..1 | date | When the incident occurred |
| .type | 0..1 | CodeableConcept | The nature of the accident Bindingv3-ActIncidentCode(extensible) |
| .location[x] | 0..1 | Address | Reference(Location) | Where the event occurred |
| .item | 0..* | BackboneElement | Product or service provided |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 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 code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Product or service billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .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 supplied Bindingservice-place(example) |
| .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 location Bindingtooth(example) |
| .subSite | 0..* | CodeableConcept | Anatomical sub-location Bindingsurface(example) |
| .encounter | 0..* | Reference(Encounter) | Encounters related to this billed item |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 0..* | BackboneElement | Adjudication details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .category | 1..1 | CodeableConcept | Type of adjudication information Bindingadjudication(example) |
| .reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Bindingadjudication-reason(example) |
| .amount | 0..1 | Money | Monetary amount |
| .value | 0..1 | decimal | Non-monitary value |
| .detail | 0..* | BackboneElement | Additional items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Product or service provided |
| .revenue | 0..1 | CodeableConcept | Revenue or cost center code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .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..* | — | Detail level adjudication details |
| .subDetail | 0..* | BackboneElement | Additional items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Product or service provided |
| .revenue | 0..1 | CodeableConcept | Revenue or cost center code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .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..* | — | Subdetail level adjudication details |
| .addItem | 0..* | BackboneElement | Insurer added line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .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 |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .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 supplied Bindingservice-place(example) |
| .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 location Bindingtooth(example) |
| .subSite | 0..* | CodeableConcept | Anatomical sub-location Bindingsurface(example) |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 0..* | — | Added items adjudication |
| .detail | 0..* | BackboneElement | Insurer added line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .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..* | — | Added items adjudication |
| .subDetail | 0..* | BackboneElement | Insurer added line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .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..* | — | Added items adjudication |
| .adjudication | 0..* | — | Header-level adjudication |
| .totalΣ | 0..* | BackboneElement | Adjudication totals |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .categoryΣ | 1..1 | CodeableConcept | Type of adjudication information Bindingadjudication(example) |
| .amountΣ | 1..1 | Money | Financial total for the category |
| .payment | 0..1 | BackboneElement | Payment Details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .type | 0..1 | CodeableConcept | Partial or complete payment Bindingex-paymenttype(example) |
| .adjustment | 0..1 | Money | Payment adjustment for non-claim issues |
| .adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Bindingpayment-adjustment-reason(example) |
| .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 identifier Bindingforms(example) |
| .form | 0..1 | Attachment | Printed reference or actual form |
| .processNote | 0..* | BackboneElement | Note concerning adjudication |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .number | 0..1 | positiveInt | Note instance identifier |
| .type | 0..1 | code | display | print | printoper Bindingnote-type(required) |
| .text | 0..1 | string | Note explanatory text |
| .language | 0..1 | CodeableConcept | Language of the text Bindinglanguages(preferred) |
| .benefitPeriod | 0..1 | Period | When the benefits are applicable |
| .benefitBalance | 0..* | BackboneElement | Balance by Benefit Category |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .category | 1..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .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 network Bindingbenefit-network(example) |
| .unit | 0..1 | CodeableConcept | Individual or family Bindingbenefit-unit(example) |
| .term | 0..1 | CodeableConcept | Annual or lifetime Bindingbenefit-term(example) |
| .financial | 0..* | BackboneElement | Benefit Summary |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .type | 1..1 | CodeableConcept | Benefit classification Bindingbenefit-type(example) |
| .allowed[x] | 0..1 | unsignedInt | string | Money | Benefits allowed |
| .used[x] | 0..1 | unsignedInt | Money | Benefits used |