NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... author[x] 0..1Insurer
.... authorIdentifierIdentifier
.... authorReferenceReference(Organization)
... claim[x] 0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] 0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... type 1..1CodingType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... billablePeriod 0..1PeriodPeriod for charge submission
... outcome 0..1Codingcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... provider[x] 0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] 0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] 0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] 0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship 0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription[x] 0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] 0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee 0..1BackboneElementPayee
.... type 0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] 0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... information 0..*BackboneElement
.... category 1..1CodingCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodingType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data
..... valueStringstring
..... valueQuantityQuantity
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis 1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
.... type 0..*CodingType of Diagnosis
Example Diagnosis Type Codes (Example)
.... drg 0..1CodingDiagnosis Related Group
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... patient[x] 1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage 1..1BackboneElementInsurance or medical plan
.... coverage[x] 0..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElement
.... date 0..1dateWhen the accident occurred
.... type 0..1CodingThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeam 0..*BackboneElement
..... provider[x] 1..1
...... providerIdentifierIdentifier
...... providerReferenceReference(Practitioner | Organization)
..... responsible 0..1booleanBilling practitioner
..... role 0..1CodingRole on the team
Claim Care Team Role Codes (Example)
..... qualification 0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodingCoding
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... points 0..1decimalDifficulty scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodingService Location
Oral Site Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... points 0..1decimalDifficulty scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodingBilling Code
USCLS Codes (Example)
...... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... points 0..1decimalDifficulty scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubDetail adjudication
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... missingTeeth 0..*BackboneElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate of Extraction
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElement
.... type 0..1CodingPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... form 0..1CodingPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodingLanguage
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory 0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit
.... network 0..1CodingIn or out of network
Network Type Codes (Example)
.... unit 0..1CodingIndividual or family
Unit Type Codes (Example)
.... term 0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] 0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitStringstring
...... benefitMoneyMoney
..... benefitUsed[x] 0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedMoneyMoney

doco Documentation for this format