STU3 Candidate

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13.6 Resource ExplanationOfBenefit - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

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.

Notice to ballotors: The name of this resource is referred to in regulations in some jurisdictions and therefor to reduce confusion or issues it may be appropriate to rename this resource, for example to ClaimSummary. Please advise the Financial Managemet Work Group if this is the case for your jurisdaiction and provide a new name recommendation.

The ExplanationOfBenefit 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 patients coverage in respect of that Claim.

This is the logical combination of the Claim, Claim Response 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 used and/or remaining.

Todo

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Insurer
... provider 0..1Reference(Practitioner)Responsible provider for the claim
... organization 0..1Reference(Organization)Responsible organization for the claim
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription
... originalPrescription 0..1Reference(MedicationRequest)Original Prescription
... payee 0..1BackboneElementPayee
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... category 1..1CodeableConceptCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingReason associated with the information
Missing Tooth Reason Codes (Example)
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's list of diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptType of Diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
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)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..1BackboneElementInsurance or medical plan
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElementDetails of an accident
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe 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
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram 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)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodeableConceptAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram 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
..... 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..1CodeableConceptType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram 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
...... 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..1CodeableConceptProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/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..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/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
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment (if paid)
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
.... subCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodeableConceptDeductable, 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

UML Diagram (Legend)

ExplanationOfBenefit (DomainResource)The EOB Business Identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)ExplanationOfBenefitStatus! »The category of claim, eg, oral, pharmacy, vision, insitutional, professionaltype : CodeableConcept [0..1] « The type or discipline-style of the claim (Strength=Required)Example Claim Type ! »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : CodeableConcept [0..*] « A more granulat claim typecode (Strength=Example)Example Claim SubType ?? »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when the EOB was createdcreated : dateTime [0..1]The person who created the explanation of benefitenterer : Reference [0..1] « Practitioner »The insurer which is responsible for the explanation of benefitinsurer : Reference [0..1] « Organization »The provider which is responsible for the claimprovider : Reference [0..1] « Practitioner »The provider which is responsible for the claimorganization : Reference [0..1] « Organization »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ReferralRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaim : Reference [0..1] « Claim »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberclaimResponse : Reference [0..1] « ClaimResponse »Processing outcome errror, partial or complete processingoutcome : CodeableConcept [0..1] « The result of the claim processing (Strength=Example)Claim Processing ?? »A description of the status of the adjudicationdisposition : string [0..1]Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superceded 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »Precedence (primary, secondary, etc.)precedence : positiveInt [0..1]The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total cost of the services reportedtotalCost : Money [0..1]The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : Money [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)totalBenefit : Money [0..1]The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »organization | patient | practitioner | relatedpersonresourceType : CodeableConcept [0..1] « The type of payee Resource (Strength=Required)PayeeResourceType! »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »SupportingInformationThe general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)Claim Information Category ?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « string|Quantity|Attachment|Reference(Any) »For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the contentreason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »CareTeamSequence of careteam which serves to order and provide a linksequence : positiveInt [1..1]The members of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|Organization »The practitioner who is billing and responsible for the claimed services rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? »The type of the Diagnosis, for example: admitting,type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example)Example Diagnosis Type ?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis (Strength=Example)Example Diagnosis Related Gro...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? »InsuranceReference to the program or plan identification, underwriter or payorcoverage : Reference [0..1] « Coverage »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]AccidentDate of an accident which these services are addressingdate : date [0..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Where the accident occurredlocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]Careteam applicable for this service or product linecareTeamLinkId : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]Procedures applicable for this service or product lineprocedureLinkId : positiveInt [0..*]Exceptions, special conditions and supporting information pplicable for this service or product lineinformationLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place where the service is rendered (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A 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 amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « Adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monitory amount associated with the codeamount : Money [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : CodeableConcept [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A 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 amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : CodeableConcept [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]A 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 amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis (Oral)priorMaterial : CodeableConcept [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemsDetailThe type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or productfee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datedate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identiferidentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : CodeableConcept [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Extensible)Common Languages+ »BenefitBalanceDental, Vision, Medical, Pharmacy, Rehab etccategory : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Money »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..1]An accident which resulted in the need for healthcare servicesaccident[0..1]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The second tier service adjudications for payor added servicesdetail[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textnote[0..*]Benefits Used to datefinancial[0..*]Balance by Benefit CategorybenefitBalance[0..*]

XML Template

<ExplanationOfBenefit xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..* CodeableConcept Finer grained claim type information --></subType>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider for the claim --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization for the claim --></organization>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <claim><!-- 0..1 Reference(Claim) Claim reference --></claim>
 <claimResponse><!-- 0..1 Reference(ClaimResponse) Claim response reference --></claimResponse>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claim -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resourceType><!-- 0..1 CodeableConcept organization | patient | practitioner | relatedperson --></resourceType>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <category><!-- 1..1 CodeableConcept Category of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 Coding Reason associated with the information --></reason>
 </information>
 <careTeam>  <!-- 0..* Care Team members -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of careteam -->
  <provider><!-- 1..1 Reference(Practitioner|Organization) Member of the Care Team --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing practitioner -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's list of diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Type of Diagnosis --></type>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <precedence value="[positiveInt]"/><!-- 0..1 Precedence (primary, secondary, etc.) -->
 <insurance>  <!-- 0..1 Insurance or medical plan -->
  <coverage><!-- 0..1 Reference(Coverage) Insurance information --></coverage>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
 </insurance>
 <accident>  <!-- 0..1 Details of an accident -->
  <date value="[date]"/><!-- 0..1 When the accident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamLinkId value="[positiveInt]"/><!-- 0..* Applicable careteam members -->
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureLinkId value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationLinkId value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Adjudication reason --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 CodeableConcept Group or type of product or service --></type>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 CodeableConcept Type of product or service --></type>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <service><!-- 0..1 CodeableConcept Billing Code --></service>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication SubDetail adjudication --></adjudication>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 CodeableConcept Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ExplanationOfBenefit.item.adjudication Added items detail adjudication --></adjudication>
  </detail>
 </addItem>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment (if paid) -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
  <language><!-- 0..1 CodeableConcept Language --></language>
 </note>
 <benefitBalance>  <!-- 0..* Balance by Benefit Category -->
  <category><!-- 1..1 CodeableConcept Benefit Category --></category>
  <subCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></subCategory>
  <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
</ExplanationOfBenefit>

JSON Template

{doco
  "resourceType" : "ExplanationOfBenefit",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : [{ CodeableConcept }], // Finer grained claim type information
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner) }, // Author
  "insurer" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider for the claim
  "organization" : { Reference(Organization) }, // Responsible organization for the claim
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "claim" : { Reference(Claim) }, // Claim reference
  "claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "related" : [{ // Related Claims which may be revelant to processing this claim
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationRequest) }, // Original Prescription
  "payee" : { // Payee
    "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other
    "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "category" : { CodeableConcept }, // R!  Category of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 4:
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { Coding } // Reason associated with the information
  }],
  "careTeam" : [{ // Care Team members
    "sequence" : "<positiveInt>", // R!  Number to covey order of careteam
    "provider" : { Reference(Practitioner|Organization) }, // R!  Member of the Care Team
    "responsible" : <boolean>, // Billing practitioner
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's list of diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Type of Diagnosis
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
  "insurance" : { // Insurance or medical plan
    "coverage" : { Reference(Coverage) }, // Insurance information
    "preAuthRef" : ["<string>"] // Pre-Authorization/Determination Reference
  },
  "accident" : { // Details of an accident
    "date" : "<date>", // When the accident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamLinkId" : ["<positiveInt>"], // Applicable careteam members
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "procedureLinkId" : ["<positiveInt>"], // Applicable procedures
    "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Adjudication reason
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { CodeableConcept }, // R!  Group or type of product or service
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { CodeableConcept }, // R!  Type of product or service
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "service" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }], // Unique Device Identifier
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // SubDetail adjudication
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { CodeableConcept } // Prosthetic Material
    }
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment (if paid)
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Reason for Payment adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "form" : { CodeableConcept }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanitory text
    "language" : { CodeableConcept } // Language
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Benefit Category
    "subCategory" : { CodeableConcept }, // Benefit SubCategory
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 3:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ExplanationOfBenefit.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:ExplanationOfBenefit.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ExplanationOfBenefit.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:ExplanationOfBenefit.subType [ CodeableConcept ], ... ; # 0..* Finer grained claim type information
  fhir:ExplanationOfBenefit.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ExplanationOfBenefit.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:ExplanationOfBenefit.created [ dateTime ]; # 0..1 Creation date
  fhir:ExplanationOfBenefit.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:ExplanationOfBenefit.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:ExplanationOfBenefit.provider [ Reference(Practitioner) ]; # 0..1 Responsible provider for the claim
  fhir:ExplanationOfBenefit.organization [ Reference(Organization) ]; # 0..1 Responsible organization for the claim
  fhir:ExplanationOfBenefit.referral [ Reference(ReferralRequest) ]; # 0..1 Treatment Referral
  fhir:ExplanationOfBenefit.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:ExplanationOfBenefit.claim [ Reference(Claim) ]; # 0..1 Claim reference
  fhir:ExplanationOfBenefit.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Claim response reference
  fhir:ExplanationOfBenefit.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ExplanationOfBenefit.disposition [ string ]; # 0..1 Disposition Message
  fhir:ExplanationOfBenefit.related [ # 0..* Related Claims which may be revelant to processing this claim
    fhir:ExplanationOfBenefit.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:ExplanationOfBenefit.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:ExplanationOfBenefit.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:ExplanationOfBenefit.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription
  fhir:ExplanationOfBenefit.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original Prescription
  fhir:ExplanationOfBenefit.payee [ # 0..1 Payee
    fhir:ExplanationOfBenefit.payee.type [ CodeableConcept ]; # 0..1 Type of party: Subscriber, Provider, other
    fhir:ExplanationOfBenefit.payee.resourceType [ CodeableConcept ]; # 0..1 organization | patient | practitioner | relatedperson
    # ExplanationOfBenefit.payee.party[x] : 0..1 Party to receive the payable. One of these 2
      fhir:ExplanationOfBenefit.payee.partyIdentifier [ Identifier ]
      fhir:ExplanationOfBenefit.payee.partyReference [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]
  ];
  fhir:ExplanationOfBenefit.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:ExplanationOfBenefit.information.category [ CodeableConcept ]; # 1..1 Category of information
    fhir:ExplanationOfBenefit.information.code [ CodeableConcept ]; # 0..1 Type of information
    # ExplanationOfBenefit.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:ExplanationOfBenefit.information.timingDate [ date ]
      fhir:ExplanationOfBenefit.information.timingPeriod [ Period ]
    # ExplanationOfBenefit.information.value[x] : 0..1 Additional Data or supporting information. One of these 4
      fhir:ExplanationOfBenefit.information.valueString [ string ]
      fhir:ExplanationOfBenefit.information.valueQuantity [ Quantity ]
      fhir:ExplanationOfBenefit.information.valueAttachment [ Attachment ]
      fhir:ExplanationOfBenefit.information.valueReference [ Reference(Any) ]
    fhir:ExplanationOfBenefit.information.reason [ Coding ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:ExplanationOfBenefit.careTeam [ # 0..* Care Team members
    fhir:ExplanationOfBenefit.careTeam.sequence [ positiveInt ]; # 1..1 Number to covey order of careteam
    fhir:ExplanationOfBenefit.careTeam.provider [ Reference(Practitioner|Organization) ]; # 1..1 Member of the Care Team
    fhir:ExplanationOfBenefit.careTeam.responsible [ boolean ]; # 0..1 Billing practitioner
    fhir:ExplanationOfBenefit.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:ExplanationOfBenefit.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:ExplanationOfBenefit.diagnosis [ # 0..* Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # ExplanationOfBenefit.diagnosis.diagnosis[x] : 1..1 Patient's list of diagnosis. One of these 2
      fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:ExplanationOfBenefit.diagnosis.type [ CodeableConcept ], ... ; # 0..* Type of Diagnosis
    fhir:ExplanationOfBenefit.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:ExplanationOfBenefit.procedure [ # 0..* Procedures performed
    fhir:ExplanationOfBenefit.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:ExplanationOfBenefit.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # ExplanationOfBenefit.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:ExplanationOfBenefit.precedence [ positiveInt ]; # 0..1 Precedence (primary, secondary, etc.)
  fhir:ExplanationOfBenefit.insurance [ # 0..1 Insurance or medical plan
    fhir:ExplanationOfBenefit.insurance.coverage [ Reference(Coverage) ]; # 0..1 Insurance information
    fhir:ExplanationOfBenefit.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
  ];
  fhir:ExplanationOfBenefit.accident [ # 0..1 Details of an accident
    fhir:ExplanationOfBenefit.accident.date [ date ]; # 0..1 When the accident occurred
    fhir:ExplanationOfBenefit.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # ExplanationOfBenefit.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:ExplanationOfBenefit.accident.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.accident.locationReference [ Reference(Location) ]
  ];
  fhir:ExplanationOfBenefit.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:ExplanationOfBenefit.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:ExplanationOfBenefit.item [ # 0..* Goods and Services
    fhir:ExplanationOfBenefit.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:ExplanationOfBenefit.item.careTeamLinkId [ positiveInt ], ... ; # 0..* Applicable careteam members
    fhir:ExplanationOfBenefit.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:ExplanationOfBenefit.item.procedureLinkId [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:ExplanationOfBenefit.item.informationLinkId [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:ExplanationOfBenefit.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.item.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ExplanationOfBenefit.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ExplanationOfBenefit.item.servicedDate [ date ]
      fhir:ExplanationOfBenefit.item.servicedPeriod [ Period ]
    # ExplanationOfBenefit.item.location[x] : 0..1 Place of service. One of these 3
      fhir:ExplanationOfBenefit.item.locationCodeableConcept [ CodeableConcept ]
      fhir:ExplanationOfBenefit.item.locationAddress [ Address ]
      fhir:ExplanationOfBenefit.item.locationReference [ Reference(Location) ]
    fhir:ExplanationOfBenefit.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:ExplanationOfBenefit.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:ExplanationOfBenefit.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ExplanationOfBenefit.item.net [ Money ]; # 0..1 Total item cost
    fhir:ExplanationOfBenefit.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:ExplanationOfBenefit.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:ExplanationOfBenefit.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:ExplanationOfBenefit.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.item.adjudication [ # 0..* Adjudication details
      fhir:ExplanationOfBenefit.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ExplanationOfBenefit.item.adjudication.reason [ CodeableConcept ]; # 0..1 Adjudication reason
      fhir:ExplanationOfBenefit.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ExplanationOfBenefit.item.adjudication.value [ decimal ]; # 0..1 Non-monitory value
    ], ...;
    fhir:ExplanationOfBenefit.item.detail [ # 0..* Additional items
      fhir:ExplanationOfBenefit.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:ExplanationOfBenefit.item.detail.type [ CodeableConcept ]; # 1..1 Group or type of product or service
      fhir:ExplanationOfBenefit.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.item.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:ExplanationOfBenefit.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:ExplanationOfBenefit.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:ExplanationOfBenefit.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ExplanationOfBenefit.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:ExplanationOfBenefit.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:ExplanationOfBenefit.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.item.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ExplanationOfBenefit.item.detail.subDetail [ # 0..* Additional items
        fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:ExplanationOfBenefit.item.detail.subDetail.type [ CodeableConcept ]; # 1..1 Type of product or service
        fhir:ExplanationOfBenefit.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:ExplanationOfBenefit.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:ExplanationOfBenefit.item.detail.subDetail.service [ CodeableConcept ]; # 0..1 Billing Code
        fhir:ExplanationOfBenefit.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ExplanationOfBenefit.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:ExplanationOfBenefit.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:ExplanationOfBenefit.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ExplanationOfBenefit.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:ExplanationOfBenefit.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
        fhir:ExplanationOfBenefit.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* SubDetail adjudication
      ], ...;
    ], ...;
    fhir:ExplanationOfBenefit.item.prosthesis [ # 0..1 Prosthetic details
      fhir:ExplanationOfBenefit.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:ExplanationOfBenefit.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:ExplanationOfBenefit.item.prosthesis.priorMaterial [ CodeableConcept ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:ExplanationOfBenefit.addItem [ # 0..* Insurer added line items
    fhir:ExplanationOfBenefit.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ExplanationOfBenefit.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ExplanationOfBenefit.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ExplanationOfBenefit.addItem.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:ExplanationOfBenefit.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ExplanationOfBenefit.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ExplanationOfBenefit.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ExplanationOfBenefit.addItem.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ExplanationOfBenefit.addItem.detail [ # 0..* Added items details
      fhir:ExplanationOfBenefit.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ExplanationOfBenefit.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ExplanationOfBenefit.addItem.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:ExplanationOfBenefit.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ExplanationOfBenefit.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ExplanationOfBenefit.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ExplanationOfBenefit.addItem.detail.adjudication [ See ExplanationOfBenefit.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ExplanationOfBenefit.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ExplanationOfBenefit.unallocDeductable [ Money ]; # 0..1 Unallocated deductable
  fhir:ExplanationOfBenefit.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ExplanationOfBenefit.payment [ # 0..1 Payment (if paid)
    fhir:ExplanationOfBenefit.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ExplanationOfBenefit.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ExplanationOfBenefit.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Reason for Payment adjustment
    fhir:ExplanationOfBenefit.payment.date [ date ]; # 0..1 Expected date of Payment
    fhir:ExplanationOfBenefit.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ExplanationOfBenefit.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ExplanationOfBenefit.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ExplanationOfBenefit.note [ # 0..* Processing notes
    fhir:ExplanationOfBenefit.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ExplanationOfBenefit.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ExplanationOfBenefit.note.text [ string ]; # 0..1 Note explanitory text
    fhir:ExplanationOfBenefit.note.language [ CodeableConcept ]; # 0..1 Language
  ], ...;
  fhir:ExplanationOfBenefit.benefitBalance [ # 0..* Balance by Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit Category
    fhir:ExplanationOfBenefit.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
    fhir:ExplanationOfBenefit.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
    fhir:ExplanationOfBenefit.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:ExplanationOfBenefit.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:ExplanationOfBenefit.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
    fhir:ExplanationOfBenefit.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
    fhir:ExplanationOfBenefit.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
    fhir:ExplanationOfBenefit.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:ExplanationOfBenefit.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
      # ExplanationOfBenefit.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitString [ string ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitMoney [ Money ]
      # ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:ExplanationOfBenefit.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
]

Changes since DSTU2

ExplanationOfBenefit
ExplanationOfBenefit.status added Element
ExplanationOfBenefit.type added Element
ExplanationOfBenefit.subType added Element
ExplanationOfBenefit.patient added Element
ExplanationOfBenefit.billablePeriod added Element
ExplanationOfBenefit.enterer added Element
ExplanationOfBenefit.insurer added Element
ExplanationOfBenefit.provider added Element
ExplanationOfBenefit.referral added Element
ExplanationOfBenefit.facility added Element
ExplanationOfBenefit.claim added Element
ExplanationOfBenefit.claimResponse added Element
ExplanationOfBenefit.outcome Type changed from code to CodeableConcept
Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ExplanationOfBenefit.related added Element
ExplanationOfBenefit.related.claim added Element
ExplanationOfBenefit.related.relationship added Element
ExplanationOfBenefit.related.reference added Element
ExplanationOfBenefit.prescription added Element
ExplanationOfBenefit.originalPrescription added Element
ExplanationOfBenefit.payee added Element
ExplanationOfBenefit.payee.type added Element
ExplanationOfBenefit.payee.resourceType added Element
ExplanationOfBenefit.payee.party[x] added Element
ExplanationOfBenefit.information added Element
ExplanationOfBenefit.information.category added Element
ExplanationOfBenefit.information.code added Element
ExplanationOfBenefit.information.timing[x] added Element
ExplanationOfBenefit.information.value[x] added Element
ExplanationOfBenefit.information.reason added Element
ExplanationOfBenefit.careTeam added Element
ExplanationOfBenefit.careTeam.sequence added Element
ExplanationOfBenefit.careTeam.provider added Element
ExplanationOfBenefit.careTeam.responsible added Element
ExplanationOfBenefit.careTeam.role added Element
ExplanationOfBenefit.careTeam.qualification added Element
ExplanationOfBenefit.diagnosis added Element
ExplanationOfBenefit.diagnosis.sequence added Element
ExplanationOfBenefit.diagnosis.diagnosis[x] added Element
ExplanationOfBenefit.diagnosis.type added Element
ExplanationOfBenefit.diagnosis.packageCode added Element
ExplanationOfBenefit.procedure added Element
ExplanationOfBenefit.procedure.sequence added Element
ExplanationOfBenefit.procedure.date added Element
ExplanationOfBenefit.procedure.procedure[x] added Element
ExplanationOfBenefit.precedence added Element
ExplanationOfBenefit.insurance added Element
ExplanationOfBenefit.insurance.coverage added Element
ExplanationOfBenefit.insurance.preAuthRef added Element
ExplanationOfBenefit.accident added Element
ExplanationOfBenefit.accident.date added Element
ExplanationOfBenefit.accident.type added Element
ExplanationOfBenefit.accident.location[x] added Element
ExplanationOfBenefit.employmentImpacted added Element
ExplanationOfBenefit.hospitalization added Element
ExplanationOfBenefit.item added Element
ExplanationOfBenefit.item.sequence added Element
ExplanationOfBenefit.item.careTeamLinkId added Element
ExplanationOfBenefit.item.diagnosisLinkId added Element
ExplanationOfBenefit.item.procedureLinkId added Element
ExplanationOfBenefit.item.informationLinkId added Element
ExplanationOfBenefit.item.revenue added Element
ExplanationOfBenefit.item.category added Element
ExplanationOfBenefit.item.service added Element
ExplanationOfBenefit.item.modifier added Element
ExplanationOfBenefit.item.programCode added Element
ExplanationOfBenefit.item.serviced[x] added Element
ExplanationOfBenefit.item.location[x] added Element
ExplanationOfBenefit.item.quantity added Element
ExplanationOfBenefit.item.unitPrice added Element
ExplanationOfBenefit.item.factor added Element
ExplanationOfBenefit.item.net added Element
ExplanationOfBenefit.item.udi added Element
ExplanationOfBenefit.item.bodySite added Element
ExplanationOfBenefit.item.subSite added Element
ExplanationOfBenefit.item.noteNumber added Element
ExplanationOfBenefit.item.adjudication added Element
ExplanationOfBenefit.item.adjudication.category added Element
ExplanationOfBenefit.item.adjudication.reason added Element
ExplanationOfBenefit.item.adjudication.amount added Element
ExplanationOfBenefit.item.adjudication.value added Element
ExplanationOfBenefit.item.detail added Element
ExplanationOfBenefit.item.detail.sequence added Element
ExplanationOfBenefit.item.detail.type added Element
ExplanationOfBenefit.item.detail.revenue added Element
ExplanationOfBenefit.item.detail.category added Element
ExplanationOfBenefit.item.detail.service added Element
ExplanationOfBenefit.item.detail.modifier added Element
ExplanationOfBenefit.item.detail.programCode added Element
ExplanationOfBenefit.item.detail.quantity added Element
ExplanationOfBenefit.item.detail.unitPrice added Element
ExplanationOfBenefit.item.detail.factor added Element
ExplanationOfBenefit.item.detail.net added Element
ExplanationOfBenefit.item.detail.udi added Element
ExplanationOfBenefit.item.detail.noteNumber added Element
ExplanationOfBenefit.item.detail.adjudication added Element
ExplanationOfBenefit.item.detail.subDetail added Element
ExplanationOfBenefit.item.detail.subDetail.sequence added Element
ExplanationOfBenefit.item.detail.subDetail.type added Element
ExplanationOfBenefit.item.detail.subDetail.revenue added Element
ExplanationOfBenefit.item.detail.subDetail.category added Element
ExplanationOfBenefit.item.detail.subDetail.service added Element
ExplanationOfBenefit.item.detail.subDetail.modifier added Element
ExplanationOfBenefit.item.detail.subDetail.programCode added Element
ExplanationOfBenefit.item.detail.subDetail.quantity added Element
ExplanationOfBenefit.item.detail.subDetail.unitPrice added Element
ExplanationOfBenefit.item.detail.subDetail.factor added Element
ExplanationOfBenefit.item.detail.subDetail.net added Element
ExplanationOfBenefit.item.detail.subDetail.udi added Element
ExplanationOfBenefit.item.detail.subDetail.noteNumber added Element
ExplanationOfBenefit.item.detail.subDetail.adjudication added Element
ExplanationOfBenefit.item.prosthesis added Element
ExplanationOfBenefit.item.prosthesis.initial added Element
ExplanationOfBenefit.item.prosthesis.priorDate added Element
ExplanationOfBenefit.item.prosthesis.priorMaterial added Element
ExplanationOfBenefit.addItem added Element
ExplanationOfBenefit.addItem.sequenceLinkId added Element
ExplanationOfBenefit.addItem.revenue added Element
ExplanationOfBenefit.addItem.category added Element
ExplanationOfBenefit.addItem.service added Element
ExplanationOfBenefit.addItem.modifier added Element
ExplanationOfBenefit.addItem.fee added Element
ExplanationOfBenefit.addItem.noteNumber added Element
ExplanationOfBenefit.addItem.adjudication added Element
ExplanationOfBenefit.addItem.detail added Element
ExplanationOfBenefit.addItem.detail.revenue added Element
ExplanationOfBenefit.addItem.detail.category added Element
ExplanationOfBenefit.addItem.detail.service added Element
ExplanationOfBenefit.addItem.detail.modifier added Element
ExplanationOfBenefit.addItem.detail.fee added Element
ExplanationOfBenefit.addItem.detail.noteNumber added Element
ExplanationOfBenefit.addItem.detail.adjudication added Element
ExplanationOfBenefit.totalCost added Element
ExplanationOfBenefit.unallocDeductable added Element
ExplanationOfBenefit.totalBenefit added Element
ExplanationOfBenefit.payment added Element
ExplanationOfBenefit.payment.type added Element
ExplanationOfBenefit.payment.adjustment added Element
ExplanationOfBenefit.payment.adjustmentReason added Element
ExplanationOfBenefit.payment.date added Element
ExplanationOfBenefit.payment.amount added Element
ExplanationOfBenefit.payment.identifier added Element
ExplanationOfBenefit.form added Element
ExplanationOfBenefit.note added Element
ExplanationOfBenefit.note.number added Element
ExplanationOfBenefit.note.type added Element
ExplanationOfBenefit.note.text added Element
ExplanationOfBenefit.note.language added Element
ExplanationOfBenefit.benefitBalance added Element
ExplanationOfBenefit.benefitBalance.category added Element
ExplanationOfBenefit.benefitBalance.subCategory added Element
ExplanationOfBenefit.benefitBalance.excluded added Element
ExplanationOfBenefit.benefitBalance.name added Element
ExplanationOfBenefit.benefitBalance.description added Element
ExplanationOfBenefit.benefitBalance.network added Element
ExplanationOfBenefit.benefitBalance.unit added Element
ExplanationOfBenefit.benefitBalance.term added Element
ExplanationOfBenefit.benefitBalance.financial added Element
ExplanationOfBenefit.benefitBalance.financial.type added Element
ExplanationOfBenefit.benefitBalance.financial.benefit[x] added Element
ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x] added Element
ExplanationOfBenefit.request deleted
ExplanationOfBenefit.ruleset deleted
ExplanationOfBenefit.originalRuleset deleted
ExplanationOfBenefit.requestProvider deleted
ExplanationOfBenefit.requestOrganization deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Insurer
... provider 0..1Reference(Practitioner)Responsible provider for the claim
... organization 0..1Reference(Organization)Responsible organization for the claim
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription
... originalPrescription 0..1Reference(MedicationRequest)Original Prescription
... payee 0..1BackboneElementPayee
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... category 1..1CodeableConceptCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingReason associated with the information
Missing Tooth Reason Codes (Example)
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's list of diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptType of Diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
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)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..1BackboneElementInsurance or medical plan
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElementDetails of an accident
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe 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
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram 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)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodeableConceptAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram 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
..... 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..1CodeableConceptType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram 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
...... 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..1CodeableConceptProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/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..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/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
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment (if paid)
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
.... subCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)