| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
| DomainResource | Explanation of Benefit resource | |||
| 0..* | Identifier | Business Identifier | ||
| ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus (Required) | |
| 0..1 | Insurer | |||
| Identifier | ||||
| Reference(Organization) | ||||
| 0..1 | Claim reference | |||
| Identifier | ||||
| Reference(Claim) | ||||
| 0..1 | Claim response reference | |||
| Identifier | ||||
| Reference(ClaimResponse) | ||||
| 1..1 | Coding | Type or discipline Example Claim Type Codes (Required) | ||
| 0..* | Coding | Finer grained claim type information Example Claim SubType Codes (Example) | ||
| 0..1 | Coding | Current specification followed Ruleset Codes (Example) | ||
| 0..1 | Coding | Original specification followed Ruleset Codes (Example) | ||
| 0..1 | dateTime | Creation date | ||
| 0..1 | Period | Period for charge submission | ||
| 0..1 | Coding | complete | error | partial Claim Processing Codes (Example) | ||
| 0..1 | string | Disposition Message | ||
| 0..1 | Responsible provider for the claim | |||
| Identifier | ||||
| Reference(Practitioner) | ||||
| 0..1 | Responsible organization for the claim | |||
| Identifier | ||||
| Reference(Organization) | ||||
| 0..1 | Servicing Facility | |||
| Identifier | ||||
| Reference(Location) | ||||
| 0..* | BackboneElement | Related Claims which may be revelant to processing this claimn | ||
| 0..1 | Reference to the related claim | |||
| Identifier | ||||
| Reference(Claim) | ||||
| 0..1 | Coding | How the reference claim is related Example Related Claim Relationship Codes (Example) | ||
| 0..1 | Identifier | Related file or case reference | ||
| 0..1 | Prescription | |||
| Identifier | ||||
| Reference(MedicationOrder | VisionPrescription) | ||||
| 0..1 | Original Prescription | |||
| Identifier | ||||
| Reference(MedicationOrder) | ||||
| 0..1 | BackboneElement | Payee | ||
| 0..1 | Coding | Type of party: Subscriber, Provider, other Payee Type Codes (Example) | ||
| 0..1 | Coding | organization | patient | practitioner | relatedperson PayeeResourceType (Required) | ||
| 0..1 | Party to receive the payable | |||
| Identifier | ||||
| Reference(Practitioner | Organization | Patient | RelatedPerson) | ||||
| 0..1 | Treatment Referral | |||
| Identifier | ||||
| Reference(ReferralRequest) | ||||
| 0..* | BackboneElement | |||
| 1..1 | Coding | Category of information Claim Information Category Codes (Example) | ||
| 0..1 | Coding | Type of information Exception Codes (Example) | ||
| 0..1 | When it occurred | |||
| date | ||||
| Period | ||||
| 0..1 | Additional Data | |||
| string | ||||
| Quantity | ||||
| 0..* | BackboneElement | Diagnosis | ||
| 1..1 | positiveInt | Number to covey order of diagnosis | ||
| 1..1 | Coding | Patient's list of diagnosis ICD-10 Codes (Example) | ||
| 0..* | Coding | Type of Diagnosis Example Diagnosis Type Codes (Example) | ||
| 0..1 | Coding | Diagnosis Related Group Example Diagnosis Related Group Codes (Example) | ||
| 0..* | BackboneElement | Procedures performed | ||
| 1..1 | positiveInt | Procedure sequence for reference | ||
| 0..1 | dateTime | When the procedure was performed | ||
| 1..1 | Patient's list of procedures performed ICD-10 Procedure Codes (Example) | |||
| Coding | ||||
| Reference(Procedure) | ||||
| 1..1 | The subject of the Products and Services | |||
| Identifier | ||||
| Reference(Patient) | ||||
| 0..1 | positiveInt | Precedence (primary, secondary, etc.) | ||
| 1..1 | BackboneElement | Insurance or medical plan | ||
| 0..1 | Insurance information | |||
| Identifier | ||||
| Reference(Coverage) | ||||
| 0..* | string | Pre-Authorization/Determination Reference | ||
| 0..1 | BackboneElement | |||
| 0..1 | date | When the accident occurred | ||
| 0..1 | Coding | The nature of the accident ActIncidentCode (Required) | ||
| 0..1 | Accident Place | |||
| Address | ||||
| Reference(Location) | ||||
| 0..1 | Period | Period unable to work | ||
| 0..1 | Period | Period in hospital | ||
| 0..* | BackboneElement | Goods and Services | ||
| 1..1 | positiveInt | Service instance | ||
| 0..* | BackboneElement | |||
| 1..1 | ||||
| Identifier | ||||
| Reference(Practitioner | Organization) | ||||
| 0..1 | boolean | Billing practitioner | ||
| 0..1 | Coding | Role on the team Claim Care Team Role Codes (Example) | ||
| 0..1 | Coding | Type, classification or Specialization Example Provider Qualification Codes (Example) | ||
| 0..* | positiveInt | Applicable diagnoses | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | Date or dates of Service | |||
| date | ||||
| Period | ||||
| 0..1 | Place of service Example Service Place Codes (Example) | |||
| Coding | ||||
| Address | ||||
| Reference(Location) | ||||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Total item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..1 | Coding | Service Location Oral Site Codes (Example) | ||
| 0..* | Coding | Service Sub-location Surface Codes (Example) | ||
| 0..* | positiveInt | List of note numbers which apply | ||
| 0..* | BackboneElement | Adjudication details | ||
| 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | ||
| 0..1 | Coding | Adjudication reason Adjudication Reason Codes (Extensible) | ||
| 0..1 | Money | Monetary amount | ||
| 0..1 | decimal | Non-monitory value | ||
| 0..* | BackboneElement | Additional items | ||
| 1..1 | positiveInt | Service instance | ||
| 1..1 | Coding | Group or type of product or service ActInvoiceGroupCode (Required) | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Total additional item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..* | positiveInt | List of note numbers which apply | ||
| 0..* | see adjudication | Detail adjudication | ||
| 0..* | BackboneElement | Additional items | ||
| 1..1 | positiveInt | Service instance | ||
| 1..1 | Coding | Type of product or service ActInvoiceGroupCode (Required) | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Net additional item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..* | positiveInt | List of note numbers which apply | ||
| 0..* | see adjudication | SubDetail adjudication | ||
| 0..1 | BackboneElement | Prosthetic details | ||
| 0..1 | boolean | Is this the initial service | ||
| 0..1 | date | Initial service Date | ||
| 0..1 | Coding | Prosthetic Material Oral Prostho Material type Codes (Example) | ||
| 0..* | BackboneElement | Insurer added line items | ||
| 0..* | positiveInt | Service instances | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..1 | Money | Professional fee or Product charge | ||
| 0..* | positiveInt | List of note numbers which apply | ||
| 0..* | see adjudication | Added items adjudication | ||
| 0..* | BackboneElement | Added items details | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..1 | Money | Professional fee or Product charge | ||
| 0..* | positiveInt | List of note numbers which apply | ||
| 0..* | see adjudication | Added items detail adjudication | ||
| 0..* | BackboneElement | Only if type = oral | ||
| 1..1 | Coding | Tooth Code Teeth Codes (Example) | ||
| 0..1 | Coding | Reason for missing Missing Tooth Reason Codes (Example) | ||
| 0..1 | date | Date of Extraction | ||
| 0..1 | Money | Total Cost of service from the Claim | ||
| 0..1 | Money | Unallocated deductable | ||
| 0..1 | Money | Total benefit payable for the Claim | ||
| 0..1 | BackboneElement | |||
| 0..1 | Coding | Partial or Complete Example Payment Type Codes (Example) | ||
| 0..1 | Money | Payment adjustment for non-Claim issues | ||
| 0..1 | Coding | Reason for Payment adjustment Payment Adjustment Reason Codes (Extensible) | ||
| 0..1 | date | Expected date of Payment | ||
| 0..1 | Money | Payment amount | ||
| 0..1 | Identifier | Payment identifier | ||
| 0..1 | Coding | Printed Form Identifier Form Codes (Required) | ||
| 0..* | BackboneElement | Processing notes | ||
| 0..1 | positiveInt | Note Number for this note | ||
| 0..1 | Coding | display | print | printoper NoteType (Required) | ||
| 0..1 | string | Note explanitory text | ||
| 0..1 | Coding | Language Common Languages (Extensible but limited to All Languages) | ||
| 0..* | BackboneElement | Balance by Benefit Category | ||
| 1..1 | Coding | Benefit Category Benefit Category Codes (Example) | ||
| 0..1 | Coding | Benefit SubCategory Benefit SubCategory Codes (Example) | ||
| 0..1 | string | Short name for the benefit | ||
| 0..1 | string | Description of the benefit | ||
| 0..1 | Coding | In or out of network Network Type Codes (Example) | ||
| 0..1 | Coding | Individual or family Unit Type Codes (Example) | ||
| 0..1 | Coding | Annual or lifetime Benefit Term Codes (Example) | ||
| 0..* | BackboneElement | Benefit Summary | ||
| 1..1 | Coding | Deductable, visits, benefit amount Benefit Type Codes (Example) | ||
| 0..1 | Benefits allowed | |||
| unsignedInt | ||||
| string | ||||
| Money | ||||
| 0..1 | Benefits used | |||
| unsignedInt | ||||
| Money | ||||
Documentation for this format | ||||