Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
TU | DomainResource | Explanation of Benefit resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
0..* | Identifier | Business Identifier for the resource | ||
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus (Required) | |
Σ | 1..1 | CodeableConcept | Category or discipline Claim Type Codes (Extensible) | |
0..1 | CodeableConcept | More granular claim type Example Claim SubType Codes (Example) | ||
Σ | 1..1 | code | claim | preauthorization | predetermination Use (Required) | |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services | |
Σ | 0..1 | Period | Relevant time frame for the claim | |
Σ | 1..1 | dateTime | Response creation date | |
0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | ||
Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |
0..1 | CodeableConcept | Desired processing urgency ProcessPriority (Example) | ||
0..1 | CodeableConcept | For whom to reserve funds FundsReserve (Example) | ||
0..1 | CodeableConcept | Funds reserved status FundsReserve (Example) | ||
0..* | BackboneElement | Prior or corollary claims | ||
0..1 | Reference(Claim) | Reference to the related claim | ||
0..1 | CodeableConcept | How the reference claim is related Example Related Claim Relationship Codes (Example) | ||
0..1 | Identifier | File or case reference | ||
0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | ||
0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | ||
0..1 | BackboneElement | Recipient of benefits payable | ||
0..1 | CodeableConcept | Category of recipient PayeeType (Example) | ||
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | ||
0..1 | Reference(ServiceRequest) | Treatment Referral | ||
0..1 | Reference(Location) | Servicing Facility | ||
0..1 | Reference(Claim) | Claim reference | ||
0..1 | Reference(ClaimResponse) | Claim response reference | ||
Σ | 1..1 | code | queued | complete | error | partial Claim Processing Codes (Required) | |
0..1 | string | Disposition Message | ||
0..* | string | Preauthorization reference | ||
0..* | Period | Preauthorization in-effect period | ||
0..* | BackboneElement | Care Team members | ||
1..1 | positiveInt | Order of care team | ||
1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | ||
0..1 | boolean | Indicator of the lead practitioner | ||
0..1 | CodeableConcept | Function within the team Claim Care Team Role Codes (Example) | ||
0..1 | CodeableConcept | Practitioner credential or specialization Example Provider Qualification Codes (Example) | ||
0..* | BackboneElement | Supporting information | ||
1..1 | positiveInt | Information instance identifier | ||
1..1 | CodeableConcept | Classification of the supplied information Claim Information Category Codes (Example) | ||
0..1 | CodeableConcept | Type of information Exception Codes (Example) | ||
0..1 | When it occurred | |||
date | ||||
Period | ||||
0..1 | Data to be provided | |||
boolean | ||||
string | ||||
Quantity | ||||
Attachment | ||||
Reference(Any) | ||||
0..1 | Coding | Explanation for the information Missing Tooth Reason Codes (Example) | ||
0..* | BackboneElement | Pertinent diagnosis information | ||
1..1 | positiveInt | Diagnosis instance identifier | ||
1..1 | Nature of illness or problem ICD-10 Codes (Example) | |||
CodeableConcept | ||||
Reference(Condition) | ||||
0..* | CodeableConcept | Timing or nature of the diagnosis Example Diagnosis Type Codes (Example) | ||
0..1 | CodeableConcept | Present on admission Example Diagnosis on Admission Codes (Example) | ||
0..1 | CodeableConcept | Package billing code Example Diagnosis Related Group Codes (Example) | ||
0..* | BackboneElement | Clinical procedures performed | ||
1..1 | positiveInt | Procedure instance identifier | ||
0..* | CodeableConcept | Category of Procedure Example Procedure Type Codes (Example) | ||
0..1 | dateTime | When the procedure was performed | ||
1..1 | Specific clinical procedure ICD-10 Procedure Codes (Example) | |||
CodeableConcept | ||||
Reference(Procedure) | ||||
0..* | Reference(Device) | Unique device identifier | ||
0..1 | positiveInt | Precedence (primary, secondary, etc.) | ||
Σ | 1..* | BackboneElement | Patient insurance information | |
Σ | 1..1 | boolean | Coverage to be used for adjudication | |
Σ | 1..1 | Reference(Coverage) | Insurance information | |
0..* | string | Prior authorization reference number | ||
0..1 | BackboneElement | Details of the event | ||
0..1 | date | When the incident occurred | ||
0..1 | CodeableConcept | The nature of the accident V3 Value SetActIncidentCode (Extensible) | ||
0..1 | Where the event occurred | |||
Address | ||||
Reference(Location) | ||||
0..* | BackboneElement | Product or service provided | ||
1..1 | positiveInt | Item instance identifier | ||
0..* | positiveInt | Applicable care team members | ||
0..* | positiveInt | Applicable diagnoses | ||
0..* | positiveInt | Applicable procedures | ||
0..* | positiveInt | Applicable exception and supporting information | ||
0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | ||
0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Product or service billing modifiers Modifier type Codes (Example) | ||
0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | ||
0..1 | Date or dates of service or product delivery | |||
date | ||||
Period | ||||
0..1 | Place of service or where product was supplied Example Service Place Codes (Example) | |||
CodeableConcept | ||||
Address | ||||
Reference(Location) | ||||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | Reference(Device) | Unique device identifier | ||
0..1 | CodeableConcept | Anatomical location Oral Site Codes (Example) | ||
0..* | CodeableConcept | Anatomical sub-location Surface Codes (Example) | ||
0..* | Reference(Encounter) | Encounters related to this billed item | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | BackboneElement | Adjudication details | ||
1..1 | CodeableConcept | Type of adjudication information Adjudication Value Codes (Example) | ||
0..1 | CodeableConcept | Explanation of adjudication outcome Adjudication Reason Codes (Example) | ||
0..1 | Money | Monetary amount | ||
0..1 | decimal | Non-monitary value | ||
0..* | BackboneElement | Additional items | ||
1..1 | positiveInt | Product or service provided | ||
0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | ||
0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | Reference(Device) | Unique device identifier | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Detail level adjudication details | ||
0..* | BackboneElement | Additional items | ||
1..1 | positiveInt | Product or service provided | ||
0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | ||
0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | Reference(Device) | Unique device identifier | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Subdetail level adjudication details | ||
0..* | BackboneElement | Insurer added line items | ||
0..* | positiveInt | Item sequence number | ||
0..* | positiveInt | Detail sequence number | ||
0..* | positiveInt | Subdetail sequence number | ||
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | ||
0..1 | Date or dates of service or product delivery | |||
date | ||||
Period | ||||
0..1 | Place of service or where product was supplied Example Service Place Codes (Example) | |||
CodeableConcept | ||||
Address | ||||
Reference(Location) | ||||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..1 | CodeableConcept | Anatomical location Oral Site Codes (Example) | ||
0..* | CodeableConcept | Anatomical sub-location Surface Codes (Example) | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Added items adjudication | ||
0..* | BackboneElement | Insurer added line items | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Added items adjudication | ||
0..* | BackboneElement | Insurer added line items | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Added items adjudication | ||
0..* | see adjudication | Header-level adjudication | ||
Σ | 0..* | BackboneElement | Adjudication totals | |
Σ | 1..1 | CodeableConcept | Type of adjudication information Adjudication Value Codes (Example) | |
Σ | 1..1 | Money | Financial total for the category | |
0..1 | BackboneElement | Payment Details | ||
0..1 | CodeableConcept | Partial or complete payment Example Payment Type Codes (Example) | ||
0..1 | Money | Payment adjustment for non-claim issues | ||
0..1 | CodeableConcept | Explanation for the variance Payment Adjustment Reason Codes (Example) | ||
0..1 | date | Expected date of payment | ||
0..1 | Money | Payable amount after adjustment | ||
0..1 | Identifier | Business identifier for the payment | ||
0..1 | CodeableConcept | Printed form identifier Forms (Example) | ||
0..1 | Attachment | Printed reference or actual form | ||
0..* | BackboneElement | Note concerning adjudication | ||
0..1 | positiveInt | Note instance identifier | ||
0..1 | code | display | print | printoper NoteType (Required) | ||
0..1 | string | Note explanatory text | ||
0..1 | CodeableConcept | Language of the text Common Languages (Preferred but limited to AllLanguages) | ||
0..1 | Period | When the benefits are applicable | ||
0..* | BackboneElement | Balance by Benefit Category | ||
1..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | ||
0..1 | boolean | Excluded from the plan | ||
0..1 | string | Short name for the benefit | ||
0..1 | string | Description of the benefit or services covered | ||
0..1 | CodeableConcept | In or out of network Network Type Codes (Example) | ||
0..1 | CodeableConcept | Individual or family Unit Type Codes (Example) | ||
0..1 | CodeableConcept | Annual or lifetime Benefit Term Codes (Example) | ||
0..* | BackboneElement | Benefit Summary | ||
1..1 | CodeableConcept | Benefit classification Benefit Type Codes (Example) | ||
0..1 | Benefits allowed | |||
unsignedInt | ||||
string | ||||
Money | ||||
0..1 | Benefits used | |||
unsignedInt | ||||
Money | ||||
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