NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
ProcessPriority (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
FundsReserve (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
FundsReserve (Example)
... related 0..*BackboneElementPrior or corollary claims
.... 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..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
PayeeType (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied 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..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
V3 Value SetActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*see adjudicationAdded items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationAdded items adjudication
... adjudication 0..*see adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Forms (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Common Languages (Preferred but limited to AllLanguages)
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... 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..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format