ExplanationOfBenefit - FHIR Resource (stu3)


This ExplanationOfBenefit Resource uses the FHIR API standard for access and structure.

Validate an ExplanationOfBenefit FHIR Resource (stu3)



Resource Attributes

AttributeField is listTypeDescription
accidentfalseData Type# Details of an accident
addItemtrueData Type# Insurer added line items
benefitBalancetrueData Type# Balance by Benefit Category
billablePeriodfalsePeriod# Period for charge submission
careTeamtrueData Type# Care Team members
claimfalseReference# Claim reference
claimResponsefalseReference# Claim response reference
createdfalsedateTime# Creation date
diagnosistrueData Type# List of Diagnosis
dispositionfalsestring# Disposition Message
employmentImpactedfalsePeriod# Period unable to work
entererfalseReference# Author
facilityfalseReference# Servicing Facility
formfalseCodeableConcept# Printed Form Identifier
hospitalizationfalsePeriod# Period in hospital
identifiertrueIdentifier# Business Identifier
informationtrueData Type# Exceptions, special considerations, the condition, situation, prior or concurrent issues
insurancefalseData Type# Insurance or medical plan
insurerfalseReference# Insurer responsible for the EOB
itemtrueData Type# Goods and Services
organizationfalseReference# Responsible organization for the claim
originalPrescriptionfalseReference# Original prescription if superceded by fulfiller
outcomefalseCodeableConcept# complete | error | partial
patientfalseReference# The subject of the Products and Services
payeefalseData Type# Party to be paid any benefits payable
paymentfalseData Type# Payment (if paid)
precedencefalsepositiveInt# Precedence (primary, secondary, etc.)
prescriptionfalseReference# Prescription authorizing services or products
proceduretrueData Type# Procedures performed
processNotetrueData Type# Processing notes
providerfalseReference# Responsible provider for the claim
referralfalseReference# Treatment Referral
relatedtrueData Type# Related Claims which may be revelant to processing this claim
statusfalsecode# active | cancelled | draft | entered-in-error
subTypetrueCodeableConcept# Finer grained claim type information
totalBenefitfalseMoney# Total benefit payable for the Claim
totalCostfalseMoney# Total Cost of service from the Claim
typefalseCodeableConcept# Type or discipline
unallocDeductablefalseMoney# Unallocated deductable

ExplanationOfBenefit Example

{
  "claim": {
    "reference": "Claim/100150"
  },
  "facility": {
    "reference": "Location/1"
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
  },
  "claimResponse": {
    "reference": "ClaimResponse/R3500"
  },
  "insurance": {
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  },
  "totalCost": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 135.57
  },
  "item": [
    {
      "service": {
        "coding": [
          {
            "code": "1200",
            "system": "http://hl7.org/fhir/service-uscls"
          }
        ]
      },
      "sequence": 1,
      "servicedDate": "2014-08-16",
      "careTeamLinkId": [
        1
      ],
      "net": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 120
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 0.8
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 96
          }
        }
      ],
      "unitPrice": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      },
      "encounter": [
        {
          "reference": "Encounter/example"
        }
      ]
    }
  ],
  "enterer": {
    "reference": "Practitioner/1"
  },
  "id": "EB3500",
  "provider": {
    "reference": "Practitioner/1"
  },
  "type": {
    "coding": [
      {
        "code": "oral",
        "system": "http://hl7.org/fhir/ex-claimtype"
      }
    ]
  },
  "status": "active",
  "patient": {
    "reference": "Patient/pat1"
  },
  "disposition": "Claim settled as per contract.",
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
      "value": "987654321"
    }
  ],
  "created": "2014-08-16",
  "resourceType": "ExplanationOfBenefit",
  "totalBenefit": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 96
  },
  "payee": {
    "resourceType": {
      "coding": [
        {
          "code": "organization",
          "system": "http://hl7.org/fhir/resource-type-link"
        }
      ]
    },
    "party": {
      "reference": "Organization/2"
    },
    "type": {
      "coding": [
        {
          "code": "provider",
          "system": "http://hl7.org/fhir/payeetype"
        }
      ]
    }
  },
  "careTeam": [
    {
      "provider": {
        "reference": "Practitioner/example"
      },
      "sequence": 1
    }
  ],
  "organization": {
    "reference": "Organization/2"
  },
  "outcome": {
    "coding": [
      {
        "code": "complete",
        "system": "http://hl7.org/fhir/remittance-outcome"
      }
    ]
  }
}

ExplanationOfBenefit Structure


  
{
  "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 responsible for the EOB
  "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 authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // Type of party: Subscriber, Provider, other
    "resourceType" : { CodeableConcept }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class 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" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the 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
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "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 }, // Explanation of Adjudication outcome
      "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 level adjudication details
      "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 }] // Language if different from the resource
      }]
    }]
  }],
  "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 }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected date of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanitory text
    "language" : { CodeableConcept } // Language if different from the resource
  }],
  "benefitBalance" : [{ // Balance by Benefit Category
    "category" : { CodeableConcept }, // R!  Type of services covered
    "subCategory" : { CodeableConcept }, // Detailed services covered within the type
    "excluded" : <boolean>, // Excluded from the plan
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit or services covered
    "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
      // allowed[x]: Benefits allowed. One of these 3:
      "allowedUnsignedInt" : "<unsignedInt>",
      "allowedString" : "<string>",
      "allowedMoney" : { Money },
      // used[x]: Benefits used. One of these 2:
      "usedUnsignedInt" : "<unsignedInt>"
      "usedMoney" : { Money }
    }]
  }]
}


 

ExplanationOfBenefit Search Parameters

The following search parameters can be used to query ExplanationOfBenefit resources. Just submit the like so:

https://api.1up.health/fhir/stu3/ExplanationOfBenefit?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
care-teamreferencecareTeam.provider
claimreferenceclaim
coveragereferenceinsurance.coverage
createddatecreated
dispositiontextdisposition
encounterreferenceitem.encounter
entererreferenceenterer
facilityreferencefacility
identifiertextidentifier
organizationreferenceorganization
patientreferencepatient
payeereferencepayee.party
providerreferenceprovider