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