Resource type: explanationofbenefit

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.

Elements

PathShortDefinitionComments
Explanation of Benefit resource Remember to uncomment ProcedureTypeThis 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.
identifierBusiness Identifier for the resourceA unique identifier assigned to this explanation of benefit.
statusactive | cancelled | draft | entered-in-errorThe status of the resource instance.This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
typeCategory or disciplineThe category of claim, e.g, oral, pharmacy, vision, institutional, professional.The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.
subTypeMore granular claim typeA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.This may contain the local bill type codes such as the US UB-04 bill type code.
useclaim | preauthorization | predeterminationA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
patientThe recipient of the products and servicesThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimburement is sought.
billablePeriodRelevant time frame for the claimThe period for which charges are being submitted.Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.
createdResponse creation dateThe date this resource was created.This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
entererAuthor of the claimIndividual who created the claim, predetermination or preauthorization.
insurerParty responsible for reimbursementThe party responsible for authorization, adjudication and reimbursement.
providerParty responsible for the claimThe provider which is responsible for the claim, predetermination or preauthorization.Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
priorityDesired processing ugencyThe provider-required urgency of processing the request. Typical values include: stat, routine deferred.If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
fundsReserveRequestedFor whom to reserve fundsA code to indicate whether and for whom funds are to be reserved for future claims.This field is only used for preauthorizations.
fundsReserveFunds reserved statusA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
relatedPrior or corollary claimsOther claims which are related to this claim such as prior submissions or claims for related services or for the same event.For example, for the original treatment and follow-up exams.
related.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
related.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
related.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
related.claimReference to the related claimReference to a related claim.
related.relationshipHow the reference claim is relatedA code to convey how the claims are related.For example, prior claim or umbrella.
related.referenceFile or case referenceAn alternate organizational reference to the case or file to which this particular claim pertains.For example, Property/Casualty insurer claim # or Workers Compensation case # .
prescriptionPrescription authorizing services or productsPrescription to support the dispensing of pharmacy, device or vision products.
originalPrescriptionOriginal prescription if superceded by fulfillerOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
payeeRecipient of benefits payableThe party to be reimbursed for cost of the products and services according to the terms of the policy.Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider are choose to pay the subscriber instead.
payee.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
payee.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payee.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payee.typeCategory of recipientType of Party to be reimbursed: Subscriber, provider, other.
payee.partyRecipient referenceReference to the individual or organization to whom any payment will be made.Not required if the payee is 'subscriber' or 'provider'.
referralTreatment ReferralA reference to a referral resource.The referral resource which lists the date, practitioner, reason and other supporting information.
facilityServicing FacilityFacility where the services were provided.
claimClaim referenceThe business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
claimResponseClaim response referenceThe business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.
outcomequeued | complete | error | partialThe outcome of the claim, predetermination, or preauthorization processing.The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
dispositionDisposition MessageA human readable description of the status of the adjudication.
preAuthRefPreauthorization referenceReference from the Insurer which is used in later communications which refers to this adjudication.This value is only present on preauthorization adjudications.
preAuthRefPeriodPreauthorization in-effect periodThe timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.This value is only present on preauthorization adjudications.
careTeamCare Team membersThe members of the team who provided the products and services.
careTeam.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
careTeam.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
careTeam.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
careTeam.sequenceOrder of care teamA number to uniquely identify care team entries.
careTeam.providerPractitioner or organizationMember of the team who provided the product or service.
careTeam.responsibleIndicator of the lead practitionerThe party who is billing and/or responsible for the claimed products or services.Responsible might not be required when there is only a single provider listed.
careTeam.roleFunction within the teamThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.Role might not be required when there is only a single provider listed.
careTeam.qualificationPractitioner credential or specializationThe qualification of the practitioner which is applicable for this service.
supportingInfoSupporting informationAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.Often there are multiple jurisdiction specific valuesets which are required.
supportingInfo.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
supportingInfo.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
supportingInfo.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
supportingInfo.sequenceInformation instance identifierA number to uniquely identify supporting information entries.
supportingInfo.categoryClassification of the supplied informationThe general class of the information supplied: information; exception; accident, employment; onset, etc.This may contain a category for the local bill type codes.
supportingInfo.codeType of informationSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.This may contain the local bill type codes such as the US UB-04 bill type code.
supportingInfo.timing[x]When it occurredThe date when or period to which this information refers.
supportingInfo.value[x]Data to be providedAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
supportingInfo.reasonExplanation for the informationProvides the reason in the situation where a reason code is required in addition to the content.For example: the reason for the additional stay, or why a tooth is missing.
diagnosisPertinent diagnosis informationInformation about diagnoses relevant to the claim items.
diagnosis.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
diagnosis.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
diagnosis.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
diagnosis.sequenceDiagnosis instance identifierA number to uniquely identify diagnosis entries.Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
diagnosis.diagnosis[x]Nature of illness or problemThe nature of illness or problem in a coded form or as a reference to an external defined Condition.
diagnosis.typeTiming or nature of the diagnosisWhen the condition was observed or the relative ranking.For example: admitting, primary, secondary, discharge.
diagnosis.onAdmissionPresent on admissionIndication of whether the diagnosis was present on admission to a facility.
diagnosis.packageCodePackage billing codeA package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
procedureClinical procedures performedProcedures performed on the patient relevant to the billing items with the claim.
procedure.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
procedure.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
procedure.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
procedure.sequenceProcedure instance identifierA number to uniquely identify procedure entries.
procedure.dateWhen the procedure was performedDate and optionally time the procedure was performed.
procedure.procedure[x]Specific clinical procedureThe code or reference to a Procedure resource which identifies the clinical intervention performed.
procedure.udiUnique device identifierUnique Device Identifiers associated with this line item.
precedencePrecedence (primary, secondary, etc.)This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.
insurancePatient insurance informationFinancial instruments for reimbursement for the health care products and services specified on the claim.All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
insurance.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.focalCoverage to be used for adjudicationA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
insurance.coverageInsurance informationReference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
insurance.preAuthRefPrior authorization reference numberReference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
accidentDetails of the eventDetails of a accident which resulted in injuries which required the products and services listed in the claim.
accident.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
accident.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
accident.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
accident.dateWhen the incident occurredDate of an accident event related to the products and services contained in the claim.The date of the accident has to preceed the dates of the products and services but within a reasonable timeframe.
accident.typeThe nature of the accidentThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
accident.location[x]Where the event occurredThe physical location of the accident event.
itemProduct or service providedA claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
item.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.sequenceItem instance identifierA number to uniquely identify item entries.
item.careTeamSequenceApplicable careteam membersCareTeam members related to this service or product.
item.diagnosisSequenceApplicable diagnosesDiagnoses applicable for this service or product.
item.procedureSequenceApplicable proceduresProcedures applicable for this service or product.
item.informationSequenceApplicable exception and supporting informationExceptions, special conditions and supporting information applicable for this service or product.
item.revenueRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.
item.categoryBenefit classificationCode to identify the general type of benefits under which products and services are provided.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
item.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
item.modifierProduct or service billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
item.programCodeProgram the product or service is provided underIdentifies the program under which this may be recovered.For example: Neonatal program, child dental program or drug users recovery program.
item.serviced[x]Date or dates of service or product deliveryThe date or dates when the service or product was supplied, performed or completed.
item.location[x]Place of service or where product was suppliedWhere the product or service was provided.
item.quantityCount of products or servicesThe number of repetitions of a service or product.
item.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
item.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
item.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
item.udiUnique device identifierUnique Device Identifiers associated with this line item.
item.bodySiteAnatomical locationPhysical service site on the patient (limb, tooth, etc.).For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
item.subSiteAnatomical sub-locationA region or surface of the bodySite, e.g. limb region or tooth surface(s).
item.encounterEncounters related to this billed itemA billed item may include goods or services provided in multiple encounters.
item.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.adjudicationAdjudication detailsIf this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
item.adjudication.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.adjudication.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.adjudication.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.adjudication.categoryType of adjudication informationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
item.adjudication.reasonExplanation of adjudication outcomeA code supporting the understanding of the adjudication result and explaining variance from expected amount.For example may indicate that the funds for this benefit type have been exhausted.
item.adjudication.amountMonetary amountMonetary amount associated with the category.For example: amount submitted, eligible amount, co-payment, and benefit payable.
item.adjudication.valueNon-monitary valueA non-monetary value associated with the category. Mutually exclusive to the amount element above.For example: eligible percentage or co-payment percentage.
item.detailAdditional itemsSecond-tier of goods and services.
item.detail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.sequenceProduct or service providedA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
item.detail.revenueRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.
item.detail.categoryBenefit classificationCode to identify the general type of benefits under which products and services are provided.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
item.detail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
item.detail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
item.detail.programCodeProgram the product or service is provided underIdentifies the program under which this may be recovered.For example: Neonatal program, child dental program or drug users recovery program.
item.detail.quantityCount of products or servicesThe number of repetitions of a service or product.
item.detail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
item.detail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
item.detail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
item.detail.udiUnique device identifierUnique Device Identifiers associated with this line item.
item.detail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.detail.adjudicationDetail level adjudication detailsThe adjudication results.
item.detail.subDetailAdditional itemsThird-tier of goods and services.
item.detail.subDetail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.subDetail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.subDetail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.subDetail.sequenceProduct or service providedA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
item.detail.subDetail.revenueRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.
item.detail.subDetail.categoryBenefit classificationCode to identify the general type of benefits under which products and services are provided.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
item.detail.subDetail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
item.detail.subDetail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
item.detail.subDetail.programCodeProgram the product or service is provided underIdentifies the program under which this may be recovered.For example: Neonatal program, child dental program or drug users recovery program.
item.detail.subDetail.quantityCount of products or servicesThe number of repetitions of a service or product.
item.detail.subDetail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
item.detail.subDetail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
item.detail.subDetail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
item.detail.subDetail.udiUnique device identifierUnique Device Identifiers associated with this line item.
item.detail.subDetail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.detail.subDetail.adjudicationSubdetail level adjudication detailsThe adjudication results.
addItemInsurer added line itemsThe first-tier service adjudications for payor added product or service lines.
addItem.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.itemSequenceItem sequence numberClaim items which this service line is intended to replace.
addItem.detailSequenceDetail sequence numberThe sequence number of the details within the claim item which this line is intended to replace.
addItem.subDetailSequenceSubdetail sequence numberThe sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
addItem.providerAuthorized providersThe providers who are authorized for the services rendered to the patient.
addItem.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.programCodeProgram the product or service is provided underIdentifies the program under which this may be recovered.For example: Neonatal program, child dental program or drug users recovery program.
addItem.serviced[x]Date or dates of service or product deliveryThe date or dates when the service or product was supplied, performed or completed.
addItem.location[x]Place of service or where product was suppliedWhere the product or service was provided.
addItem.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.bodySiteAnatomical locationPhysical service site on the patient (limb, tooth, etc.).For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
addItem.subSiteAnatomical sub-locationA region or surface of the bodySite, e.g. limb region or tooth surface(s).
addItem.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.adjudicationAdded items adjudicationThe adjudication results.
addItem.detailInsurer added line itemsThe second-tier service adjudications for payor added services.
addItem.detail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.detail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.detail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.detail.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.detail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.detail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.detail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.detail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.detail.adjudicationAdded items adjudicationThe adjudication results.
addItem.detail.subDetailInsurer added line itemsThe third-tier service adjudications for payor added services.
addItem.detail.subDetail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.detail.subDetail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.subDetail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.subDetail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.detail.subDetail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.detail.subDetail.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.detail.subDetail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.detail.subDetail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.detail.subDetail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.detail.subDetail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.detail.subDetail.adjudicationAdded items adjudicationThe adjudication results.
adjudicationHeader-level adjudicationThe adjudication results which are presented at the header level rather than at the line-item or add-item levels.
totalAdjudication totalsCategorized monetary totals for the adjudication.Totals for amounts submitted, co-pays, benefits payable etc.
total.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
total.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
total.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
total.categoryType of adjudication informationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
total.amountFinancial total for the categoryMonetary total amount associated with the category.
paymentPayment DetailsPayment details for the adjudication of the claim.
payment.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
payment.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payment.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payment.typePartial or complete paymentWhether this represents partial or complete payment of the benefits payable.
payment.adjustmentPayment adjustment for non-claim issuesTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
payment.adjustmentReasonExplanation for the varianceReason for the payment adjustment.
payment.dateExpected date of paymentEstimated date the payment will be issued or the actual issue date of payment.
payment.amountPayable amount after adjustmentBenefits payable less any payment adjustment.
payment.identifierBusiness identifier for the paymentIssuer's unique identifier for the payment instrument.For example: EFT number or check number.
formCodePrinted form identifierA code for the form to be used for printing the content.May be needed to identify specific jurisdictional forms.
formPrinted reference or actual formThe actual form, by reference or inclusion, for printing the content or an EOB.Needed to permit insurers to include the actual form.
processNoteNote concerning adjudicationA note that describes or explains adjudication results in a human readable form.
processNote.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
processNote.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
processNote.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
processNote.numberNote instance identifierA number to uniquely identify a note entry.
processNote.typedisplay | print | printoperThe business purpose of the note text.
processNote.textNote explanitory textThe explanation or description associated with the processing.
processNote.languageLanguage of the textA code to define the language used in the text of the note.Only requred if the language is different from the resource language.
benefitPeriodWhen the benefits are applicableThe term of the benefits documented in this response.Not applicable when use=claim.
benefitBalanceBalance by Benefit CategoryBalance by Benefit Category.
benefitBalance.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
benefitBalance.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
benefitBalance.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
benefitBalance.categoryBenefit classificationCode to identify the general type of benefits under which products and services are provided.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
benefitBalance.excludedExcluded from the planTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
benefitBalance.nameShort name for the benefitA short name or tag for the benefit.For example: MED01, or DENT2.
benefitBalance.descriptionDescription of the benefit or services coveredA richer description of the benefit or services covered.For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
benefitBalance.networkIn or out of networkIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
benefitBalance.unitIndividual or familyIndicates if the benefits apply to an individual or to the family.
benefitBalance.termAnnual or lifetimeThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
benefitBalance.financialBenefit SummaryBenefits Used to date.
benefitBalance.financial.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
benefitBalance.financial.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
benefitBalance.financial.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
benefitBalance.financial.typeBenefit classificationClassification of benefit being provided.For example: deductible, visits, benefit amount.
benefitBalance.financial.allowed[x]Benefits allowedThe quantity of the benefit which is permitted under the coverage.
benefitBalance.financial.used[x]Benefits usedThe quantity of the benefit which have been consumed to date.

Scope and Usage

The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.

This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information in respect of a single payor prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payor which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.

Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. It may also be used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. An EOB will never be created for patient or subscriber information exchange if an error was detected in the Claim.

It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. When the resource was originally being developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource for multiple purposes.

Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if the payee is the provider as that would leak business confidential information.

Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. Only the ClaimResponse contains the appropriate adjudication information for a payor response to a Claim.

The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional Information

Additional information regarding electronic claims content and usage may be found at:

Boundaries and Relationships

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.

The eClaim domain includes a number of related resources
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.


Search Parameters

care-teamMember of the CareTeamExplanationOfBenefit.careTeam.provider
claimThe reference to the claimExplanationOfBenefit.claim
coverageThe plan under which the claim was adjudicatedExplanationOfBenefit.insurance.coverage
createdThe creation date for the EOBExplanationOfBenefit.created
detail-udiUDI associated with a line item detail product or serviceExplanationOfBenefit.item.detail.udi
dispositionThe contents of the disposition messageExplanationOfBenefit.disposition
encounterEncounters associated with a billed line itemExplanationOfBenefit.item.encounter
entererThe party responsible for the entry of the ClaimExplanationOfBenefit.enterer
facilityFacility responsible for the goods and servicesExplanationOfBenefit.facility
identifierThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier
item-udiUDI associated with a line item product or serviceExplanationOfBenefit.item.udi
patientThe reference to the patientExplanationOfBenefit.patient
payeeThe party receiving any payment for the ClaimExplanationOfBenefit.payee.party
procedure-udiUDI associated with a procedureExplanationOfBenefit.procedure.udi
providerThe reference to the providerExplanationOfBenefit.provider
statusStatus of the instanceExplanationOfBenefit.status
subdetail-udiUDI associated with a line item detail subdetail product or serviceExplanationOfBenefit.item.detail.subDetail.udi

Extension Definitions

These are extension definitions for this resource defined by the spec