This page is part of a downloaded copy of this specification. This page is part of the CARIN Blue Button Implementation Guide (v0.1.0: STU1 Ballot 1) based on FHIR R4. For a full list of available versions, see the Directory of published versions
EOB Comprehensive mapping
[Previous Page](undefined)Slice | L0 | L1 | L2 | L3 | L4 | Flag | Cardinality | DataType / Value Set |
Description | |||||
ExplanationOfBenefit | TU | DomainResource | Explanation of Benefit resource | |||||||||||
ExplanationOfBenefit | Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |||||||||||||
ExplanationOfBenefit | identifier | 1..* | Identifier | Business Identifier for the resource | ||||||||||
ExplanationOfBenefit | status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error | |||||||||
ExplanationOfBenefit | status | ExplanationOfBenefitStatus (Required) | ||||||||||||
ExplanationOfBenefit | type | Σ | 1..1 | CodeableConcept | Category or discipline | |||||||||
ExplanationOfBenefit | type | Claim Type Codes (Extensible) | ||||||||||||
ExplanationOfBenefit | subtype | 0..1 | CodeableConcept | More granular claim type | ||||||||||
ExplanationOfBenefit | subtype | Example Claim SubType Codes (Example) | ||||||||||||
ExplanationOfBenefit | use | Σ | 1..1 | code | claim | preauthorization | predetermination | |||||||||
ExplanationOfBenefit | use | Use (Required) | ||||||||||||
ExplanationOfBenefit | patient--> | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | |||||||||
ExplanationOfBenefit | billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | |||||||||
ExplanationOfBenefit | created | Σ | 1..1 | dateTime | Response creation date | |||||||||
ExplanationOfBenefit | enterer--> | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | ||||||||||
ExplanationOfBenefit | insurer--> | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | |||||||||
ExplanationOfBenefit | provider--> | Σ | 1..1 | Reference(PractionerRole) | Party responsible for the claim | |||||||||
ExplanationOfBenefit | priority | 0..1 | CodeableConcept | Desired processing urgency | ||||||||||
ExplanationOfBenefit | priority | ProcessPriority | ||||||||||||
ExplanationOfBenefit | fundsReservedRequested | 0..1 | CodeableConcept | For whom to reserve funds | ||||||||||
ExplanationOfBenefit | fundsReservedRequested | FundsReserve (Example) | ||||||||||||
ExplanationOfBenefit | fundsReserve | 0..1 | CodeableConcept | Funds reserved status | ||||||||||
ExplanationOfBenefit | fundsReserve | FundsReserve (Example) | ||||||||||||
ExplanationOfBenefit | related | 0..* | BackboneElement | Prior or corollary claims | ||||||||||
ExplanationOfBenefit | related | claim--> | 0..1 | Reference(Claim) | Reference to the related claim | |||||||||
ExplanationOfBenefit | related | relationship | 0..1 | CodeableConcept | How the reference claim is related | |||||||||
ExplanationOfBenefit | related | relationship | Example Related Claim Relationship Codes (Example) | |||||||||||
ExplanationOfBenefit | related | reference | 0..1 | Identifier | File or case reference | |||||||||
ExplanationOfBenefit | prescription--> | 0..1 | Reference(MedicationRequest| VisionPrescription) | Prescription authorizing services or products | ||||||||||
ExplanationOfBenefit | originalPrescription--> | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | ||||||||||
ExplanationOfBenefit | payee | 0..1 | BackboneElement | Recipient of benefits payable | ||||||||||
ExplanationOfBenefit | payee | type | 0..1 | CodeableConcept | Category of recipient | |||||||||
ExplanationOfBenefit | payee | type | PayeeType (Example) | |||||||||||
ExplanationOfBenefit | payee | party--> | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||||||
ExplanationOfBenefit | referral--> | 0..1 | Reference(ServiceRequest) | Treatment Referral | ||||||||||
ExplanationOfBenefit | facility--> | 0..1 | Reference(Location) | Servicing Facility | ||||||||||
ExplanationOfBenefit | claim--> | 0..1 | Reference(Claim) | Claim reference | ||||||||||
ExplanationOfBenefit | claimResponse--> | 0..1 | Reference(ClaimResponse) | Claim response reference | ||||||||||
ExplanationOfBenefit | outcome | Σ | 1..1 | code | queued | complete | error | partial | |||||||||
ExplanationOfBenefit | outcome | Claim Processing Codes (Required) | ||||||||||||
ExplanationOfBenefit | disposition | 0..1 | string | Disposition Message | ||||||||||
ExplanationOfBenefit | preAuthRef | 0..* | string | Preauthorization reference | ||||||||||
ExplanationOfBenefit | preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | ||||||||||
ExplanationOfBenefit | careTeam | 0..* | BackboneElement | Care Team members | ||||||||||
ExplanationOfBenefit | careTeam | sequence | 1..1 | positiveInt | Order of care team | |||||||||
ExplanationOfBenefit | careTeam | provider--> | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||||||
ExplanationOfBenefit | careTeam | responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||||||
ExplanationOfBenefit | careTeam | role | 0..1 | CodeableConcept | Function within the team | |||||||||
ExplanationOfBenefit | careTeam | role | Claim Care Team Role Codes (Example) | |||||||||||
ExplanationOfBenefit | careTeam | qualification | 0..1 | CodeableConcept | Practitioner credential or specialization | |||||||||
ExplanationOfBenefit | careTeam | qualification | Example Provider Qualification Codes (Example) | |||||||||||
ExplanationOfBenefit | supportingInfo | 1..* | BackboneElement | Supporting information | ||||||||||
ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | |||||||||
ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | |||||||||
ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | |||||||||||
ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | |||||||||
ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | |||||||||||
ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | ||||||||||
ExplanationOfBenefit | supportingInfo | timing | timingDate | date | ||||||||||
ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | ||||||||||
ExplanationOfBenefit | supportingInfo | value | 1..1 | Data to be provided | ||||||||||
ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | ||||||||||
ExplanationOfBenefit | supportingInfo | value | valueString | string | ||||||||||
ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | ||||||||||
ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | ||||||||||
ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | ||||||||||
ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | |||||||||
ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | ||||||||||
ExplanationOfBenefit | diagnosis | sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||||||
ExplanationOfBenefit | diagnosis | diagnosis | 1..1 | CodeableConcept | Nature of illness or problem | |||||||||
ExplanationOfBenefit | diagnosis | diagnosis | ICD-10 Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | diagnosis | Reference(Condition) | |||||||||||
ExplanationOfBenefit | diagnosis | type | 0..* | CodeableConcept | Timing or nature of the diagnosis | |||||||||
ExplanationOfBenefit | diagnosis | type | Example Diagnosis Type Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | onAdmission | 0..1 | CodeableConcept | Present on admission | |||||||||
ExplanationOfBenefit | diagnosis | onAdmission | Example Diagnosis on Admission Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | packageCode | 0..1 | CodeableConcept | Package billing code | |||||||||
ExplanationOfBenefit | diagnosis | packageCode | Example Diagnosis Related Group Codes (Example) | |||||||||||
ExplanationOfBenefit | procedure | 0..* | BackboneElement | Clinical procedures performed | ||||||||||
ExplanationOfBenefit | procedure | sequence | 1..1 | positiveInt | Procedure instance identifier | |||||||||
ExplanationOfBenefit | procedure | type | 0..* | CodeableConcept | Category of Procedure | |||||||||
ExplanationOfBenefit | procedure | type | Example Procedure Type Codes (Example) | |||||||||||
ExplanationOfBenefit | procedure | date | 0..1 | dateTime | When the procedure was performed | |||||||||
ExplanationOfBenefit | procedure | procedure | 1..1 | Specific clinical procedure | ||||||||||
ExplanationOfBenefit | procedure | procedure | ICD-10 Procedure Codes (Example) | |||||||||||
ExplanationOfBenefit | procedure | procedure | procedureCodeableConcept | CodeableConcept | ||||||||||
ExplanationOfBenefit | procedure | procedure | procedureReference--> | Reference(Procedure) | ||||||||||
ExplanationOfBenefit | procedure | udi | 0..* | Reference(Device) | Unique device identifier | |||||||||
ExplanationOfBenefit | precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | ||||||||||
ExplanationOfBenefit | insurance | Σ | 1..* | BackboneElement | Patient insurance information | |||||||||
ExplanationOfBenefit | insurance | focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||||||
ExplanationOfBenefit | insurance | preAuthRef | 0..* | string | Prior authorization reference number | |||||||||
ExplanationOfBenefit | accident | 0..1 | BackboneElement | Details of the event | ||||||||||
ExplanationOfBenefit | accident | date | 0..1 | date | When the incident occurred | |||||||||
ExplanationOfBenefit | accident | type | 0..1 | CodeableConcept | The nature of the accident | |||||||||
ExplanationOfBenefit | accident | type | V3 Value SetActIncidentCode (Extensible) | |||||||||||
ExplanationOfBenefit | accident | location | 0..1 | Where the event occurred | ||||||||||
ExplanationOfBenefit | accident | location | locationAddress | Address | ||||||||||
ExplanationOfBenefit | accident | location | locationReference | Reference(Location) | ||||||||||
ExplanationOfBenefit | item | 0..* | BackboneElement | Product or service provided | ||||||||||
ExplanationOfBenefit | item | sequence | 1..1 | positiveInt | Item instance identifier | |||||||||
ExplanationOfBenefit | item | careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||||||
ExplanationOfBenefit | item | diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||||||
ExplanationOfBenefit | item | procedureSequence | 0..* | positiveInt | Applicable procedures | |||||||||
ExplanationOfBenefit | item | informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||||||
ExplanationOfBenefit | item | revenue | 0..1 | CodeableConcept | Revenue or cost center code | |||||||||
ExplanationOfBenefit | item | revenue | Example Revenue Center Codes (Example) | |||||||||||
ExplanationOfBenefit | item | category | 0..1 | CodeableConcept | Benefit classification | |||||||||
ExplanationOfBenefit | item | category | Benefit Category Codes (Example) | |||||||||||
ExplanationOfBenefit | item | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||||
ExplanationOfBenefit | item | productOrService | USCLS Codes (Example) | |||||||||||
ExplanationOfBenefit | item | modifier | 0..* | CodeableConcept | Product or service billing modifiers | |||||||||
ExplanationOfBenefit | item | modifier | Modifier type Codes (Example) | |||||||||||
ExplanationOfBenefit | item | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||||
ExplanationOfBenefit | item | programCode | Example Program Reason Codes (Example) | |||||||||||
ExplanationOfBenefit | item | serviced | 0..1 | Date or dates of service or product delivery | ||||||||||
ExplanationOfBenefit | item | serviced | servicedDate | date | Date or dates of service or product delivery | |||||||||
ExplanationOfBenefit | item | serviced | servicedPeriod | Period | Date or dates of service or product delivery | |||||||||
ExplanationOfBenefit | item | location | 0..1 | Place of service or where product was supplied | ||||||||||
ExplanationOfBenefit | item | location | Example Service Place Codes (Example) | |||||||||||
ExplanationOfBenefit | item | location | locationCodeableConcept | CodeableConcept | ||||||||||
ExplanationOfBenefit | item | location | locationAddress | Address | ||||||||||
ExplanationOfBenefit | item | location | locationReference--> | Reference(Location) | ||||||||||
ExplanationOfBenefit | item | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||||
ExplanationOfBenefit | item | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||
ExplanationOfBenefit | item | factor | 0..1 | decimal | Price scaling factor | |||||||||
ExplanationOfBenefit | item | net | 0..1 | Money | Total item cost | |||||||||
ExplanationOfBenefit | item | udi--> | 0..* | Reference(Device) | Unique device identifier | |||||||||
ExplanationOfBenefit | item | bodySite | 0..1 | CodeableConcept | Anatomical location | |||||||||
ExplanationOfBenefit | item | bodySite | Oral Site Codes (Example) | |||||||||||
ExplanationOfBenefit | item | subSite | 0..* | CodeableConcept | Anatomical sub-location | |||||||||
ExplanationOfBenefit | item | subSite | Surface Codes (Example) | |||||||||||
ExplanationOfBenefit | item | encounter--> | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||||||
ExplanationOfBenefit | item | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||||
ExplanationOfBenefit | item | adjudication | 0..* | BackboneElement | Adjudication details | |||||||||
ExplanationOfBenefit | item | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | ||||||||
ExplanationOfBenefit | item | adjudication | category | Adjudication Value Codes (Example) | ||||||||||
ExplanationOfBenefit | item | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | ||||||||
ExplanationOfBenefit | item | adjudication | reason | Adjudication Reason Codes (Example) | ||||||||||
ExplanationOfBenefit | item | adjudication | amount | 0..1 | Money | Monetary amount | ||||||||
ExplanationOfBenefit | item | adjudication | value | 0..1 | decimal | Non-monitary value | ||||||||
ExplanationOfBenefit | item | detail | value | 0..* | BackboneElement | Additional items | ||||||||
ExplanationOfBenefit | item | detail | sequence | 1..1 | positiveInt | Product or service provided | ||||||||
ExplanationOfBenefit | item | detail | revenue | 0..1 | CodeableConcept | Revenue or cost center code | ||||||||
ExplanationOfBenefit | item | detail | revenue | Example Revenue Center Codes (Example) | ||||||||||
ExplanationOfBenefit | item | detail | category | 0..1 | CodeableConcept | Benefit classification | ||||||||
ExplanationOfBenefit | item | detail | category | Benefit Category Codes (Example) | ||||||||||
ExplanationOfBenefit | item | detail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | ||||||||
ExplanationOfBenefit | item | detail | productOrService | USCLS Codes (Example) | ||||||||||
ExplanationOfBenefit | item | detail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | ||||||||
ExplanationOfBenefit | item | detail | modifier | Modifier type Codes (Example) | ||||||||||
ExplanationOfBenefit | item | detail | programCode | 0..* | CodeableConcept | Program the product or service is provided under | ||||||||
ExplanationOfBenefit | item | detail | programCode | Example Program Reason Codes (Example) | ||||||||||
ExplanationOfBenefit | item | detail | quantity | 0..1 | SimpleQuantity | Count of products or services | ||||||||
ExplanationOfBenefit | item | detail | unitPrice | 0..1 | Money | Fee, charge or cost per item | ||||||||
ExplanationOfBenefit | item | detail | factor | 0..1 | decimal | Price scaling factor | ||||||||
ExplanationOfBenefit | item | detail | net | 0..1 | Money | Total item cost | ||||||||
ExplanationOfBenefit | item | detail | udi--> | 0..* | Reference(Device) | Unique device identifier | ||||||||
ExplanationOfBenefit | item | detail | noteNumber | 0..* | positiveInt | Applicable note numbers | ||||||||
ExplanationOfBenefit | item | detail | adjudication | 0..* | see adjudication | Detail level adjudication details | ||||||||
ExplanationOfBenefit | item | detail | subDetail | 0..* | BackboneElement | Additional items | ||||||||
ExplanationOfBenefit | item | detail | subDetail | sequence | 1..1 | positiveInt | Product or service provided | |||||||
ExplanationOfBenefit | item | detail | subDetail | revenue | 0..1 | CodeableConcept | Revenue or cost center code | |||||||
ExplanationOfBenefit | item | detail | subDetail | revenue | Example Revenue Center Codes (Example) | |||||||||
ExplanationOfBenefit | item | detail | subDetail | category | 0..1 | CodeableConcept | Benefit classification | |||||||
ExplanationOfBenefit | item | detail | subDetail | category | Benefit Category Codes (Example) | |||||||||
ExplanationOfBenefit | item | detail | subDetail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||
ExplanationOfBenefit | item | detail | subDetail | productOrService | USCLS Codes (Example) | |||||||||
ExplanationOfBenefit | item | detail | subDetail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||
ExplanationOfBenefit | item | detail | subDetail | modifier | Modifier type Codes (Example) | |||||||||
ExplanationOfBenefit | item | detail | subDetail | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||
ExplanationOfBenefit | item | detail | subDetail | programCode | Example Program Reason Codes (Example) | |||||||||
ExplanationOfBenefit | item | detail | subDetail | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||
ExplanationOfBenefit | item | detail | subDetail | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||
ExplanationOfBenefit | item | detail | subDetail | factor | 0..1 | decimal | Price scaling factor | |||||||
ExplanationOfBenefit | item | detail | subDetail | net | 0..1 | Money | Total item cost | |||||||
ExplanationOfBenefit | item | detail | subDetail | udi | 0..* | Reference(Device) | Unique device identifier | |||||||
ExplanationOfBenefit | item | detail | subDetail | note | 0..* | positiveInt | Applicable note numbers | |||||||
ExplanationOfBenefit | item | detail | subDetail | adjudication | 0..* | see adjudication | Subdetail level adjudication details | |||||||
ExplanationOfBenefit | additem | 0..* | BackboneElement | Insurer added line items | ||||||||||
ExplanationOfBenefit | additem | itemSequence | 0..* | positiveInt | Item sequence number | |||||||||
ExplanationOfBenefit | additem | detailSequence | 0..* | positiveInt | Detail sequence number | |||||||||
ExplanationOfBenefit | additem | subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||||||
ExplanationOfBenefit | additem | provider--> | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||||||
ExplanationOfBenefit | additem | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||||
ExplanationOfBenefit | additem | productOrService | USCLS Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||||
ExplanationOfBenefit | additem | modifier | Modifier type Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||||
ExplanationOfBenefit | additem | programCode | Example Program Reason Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||||||
ExplanationOfBenefit | additem | serviced[x] | servicedDate | date | ||||||||||
ExplanationOfBenefit | additem | serviced[x] | servicedPeriod | Period | ||||||||||
ExplanationOfBenefit | additem | location[x] | 0..1 | Place of service or where product was supplied | ||||||||||
ExplanationOfBenefit | additem | location[x] | Example Service Place Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | location[x] | locationCodeableConcept | CodeableConcept | ||||||||||
ExplanationOfBenefit | additem | location[x] | locationAddress | Address | ||||||||||
ExplanationOfBenefit | additem | location[x] | locationReference--> | Reference(Location) | ||||||||||
ExplanationOfBenefit | additem | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||||
ExplanationOfBenefit | additem | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||
ExplanationOfBenefit | additem | factor | 0..1 | decimal | Price scaling factor | |||||||||
ExplanationOfBenefit | additem | net | 0..1 | Money | Total item cost | |||||||||
ExplanationOfBenefit | additem | bodySite | 0..1 | CodeableConcept | Anatomical location | |||||||||
ExplanationOfBenefit | additem | bodySite | Oral Site Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | subSite | 0..* | CodeableConcept | Anatomical sub-location | |||||||||
ExplanationOfBenefit | additem | subSite | Surface Codes (Example) | |||||||||||
ExplanationOfBenefit | additem | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||||
ExplanationOfBenefit | additem | adjudication | 0..* | see adjudication | Added items adjudication | |||||||||
ExplanationOfBenefit | additem | detail | 0..* | BackboneElement | Insurer added line items | |||||||||
ExplanationOfBenefit | additem | detail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | ||||||||
ExplanationOfBenefit | additem | detail | productOrService | USCLS Codes (Example) | ||||||||||
ExplanationOfBenefit | additem | detail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | ||||||||
ExplanationOfBenefit | additem | detail | modifier | Modifier type Codes (Example) | ||||||||||
ExplanationOfBenefit | additem | detail | quantity | 0..1 | SimpleQuantity | Count of products or services | ||||||||
ExplanationOfBenefit | additem | detail | unitPrice | 0..1 | Money | Fee, charge or cost per item | ||||||||
ExplanationOfBenefit | additem | detail | factor | 0..1 | decimal | Price scaling factor | ||||||||
ExplanationOfBenefit | additem | detail | net | 0..1 | Money | Total item cost | ||||||||
ExplanationOfBenefit | additem | detail | noteNumber | 0..* | positiveInt | Applicable note numbers | ||||||||
ExplanationOfBenefit | additem | detail | adjudication | 0..* | see adjudication | Added items adjudication | ||||||||
ExplanationOfBenefit | additem | detail | subDetail | 0..* | BackboneElement | Insurer added line items | ||||||||
ExplanationOfBenefit | additem | detail | subDetail | ProductOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||
ExplanationOfBenefit | additem | detail | subDetail | ProductOrService | USCLS Codes (Example) | |||||||||
ExplanationOfBenefit | additem | detail | subDetail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||
ExplanationOfBenefit | additem | detail | subDetail | modifier | Modifier type Codes (Example) | |||||||||
ExplanationOfBenefit | additem | detail | subDetail | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||
ExplanationOfBenefit | additem | detail | subDetail | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||
ExplanationOfBenefit | additem | detail | subDetail | factor | 0..1 | decimal | Price scaling factor | |||||||
ExplanationOfBenefit | additem | detail | subDetail | net | 0..1 | Money | Total item cost | |||||||
ExplanationOfBenefit | additem | detail | subDetail | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||
ExplanationOfBenefit | additem | detail | subDetail | adjudication | 0..* | see adjudication | Added items adjudication | |||||||
ExplanationOfBenefit | adjudication | 0..* | see adjudication | Header-level adjudication | ||||||||||
ExplanationOfBenefit | total | Σ | 1..* | BackboneElement | Adjudication totals | |||||||||
ExplanationOfBenefit | total | category | Σ | 1..1 | CodeableConcept | Type of adjudication information | ||||||||
ExplanationOfBenefit | total | category | Adjudication Value Codes (Example) | |||||||||||
ExplanationOfBenefit | total | amount | Σ | 1..1 | Money | Financial total for the category | ||||||||
ExplanationOfBenefit | payment | 0..1 | BackboneElement | Payment Details | ||||||||||
ExplanationOfBenefit | payment | type | 0..1 | CodeableConcept | Partial or complete payment | |||||||||
ExplanationOfBenefit | payment | type | Example Payment Type Codes (Example) | |||||||||||
ExplanationOfBenefit | payment | adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||||||
ExplanationOfBenefit | payment | adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance | |||||||||
ExplanationOfBenefit | payment | adjustmentReason | Payment Adjustment Reason Codes (Example) | |||||||||||
ExplanationOfBenefit | payment | date | 0..1 | date | Expected date of payment | |||||||||
ExplanationOfBenefit | payment | amount | 0..1 | Money | Payable amount after adjustment | |||||||||
ExplanationOfBenefit | payment | identifier | 0..1 | Identifier | Business identifier for the payment | |||||||||
ExplanationOfBenefit | formCode | 0..1 | CodeableConcept | Printed form identifier | ||||||||||
ExplanationOfBenefit | formCode | Forms (Example) | ||||||||||||
ExplanationOfBenefit | form | 0..1 | Attachment | Printed reference or actual form | ||||||||||
ExplanationOfBenefit | processNote | 0..* | BackboneElement | Note concerning adjudication | ||||||||||
ExplanationOfBenefit | processNote | number | 0..1 | positiveInt | Note instance identifier | |||||||||
ExplanationOfBenefit | processNote | type | 0..1 | code | display | print | printoper | |||||||||
ExplanationOfBenefit | processNote | type | NoteType (Required) | |||||||||||
ExplanationOfBenefit | processNote | text | 0..1 | string | Note explanatory text | |||||||||
ExplanationOfBenefit | processNote | language | 0..1 | CodeableConcept | Language of the text | |||||||||
ExplanationOfBenefit | processNote | language | Common Languages (Preferred but limited to AllLanguages) | |||||||||||
ExplanationOfBenefit | benefitPeriod | 0..1 | Period | When the benefits are applicable | ||||||||||
ExplanationOfBenefit | benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | ||||||||||
ExplanationOfBenefit | benefitBalance | category | 1..1 | CodeableConcept | Benefit classification | |||||||||
ExplanationOfBenefit | benefitBalance | category | Benefit Category Codes (Example) | |||||||||||
ExplanationOfBenefit | benefitBalance | excluded | 0..1 | boolean | Excluded from the plan | |||||||||
ExplanationOfBenefit | benefitBalance | name | 0..1 | string | Short name for the benefit | |||||||||
ExplanationOfBenefit | benefitBalance | description | 0..1 | string | Description of the benefit or services covered | |||||||||
ExplanationOfBenefit | benefitBalance | network | 0..1 | CodeableConcept | In or out of network | |||||||||
ExplanationOfBenefit | benefitBalance | network | Network Type Codes (Example) | |||||||||||
ExplanationOfBenefit | benefitBalance | unit | 0..1 | CodeableConcept | Individual or family | |||||||||
ExplanationOfBenefit | benefitBalance | unit | Unit Type Codes (Example) | |||||||||||
ExplanationOfBenefit | benefitBalance | term | 0..1 | CodeableConcept | Annual or lifetime | |||||||||
ExplanationOfBenefit | benefitBalance | term | Benefit Term Codes (Example) | |||||||||||
ExplanationOfBenefit | benefitBalance | financial | 0..* | BackboneElement | Benefit Summary | |||||||||
ExplanationOfBenefit | benefitBalance | financial | type | 1..1 | CodeableConcept | Benefit classification | ||||||||
ExplanationOfBenefit | benefitBalance | financial | type | Benefit Type Codes (Example) | ||||||||||
ExplanationOfBenefit | benefitBalance | allowed | 0..1 | Benefits allowed | ||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedUnsignedInt | unsignedInt | ||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedString | string | ||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedMoney | Money | ||||||||||
ExplanationOfBenefit | benefitBalance | used | 0..1 | Benefits used | ||||||||||
ExplanationOfBenefit | benefitBalance | used | usedUnsignedInt | unsignedInt | ||||||||||
ExplanationOfBenefit | benefitBalance | used | usedMoney | Money | ||||||||||