ExplanationOfBenefit - FHIR Resource (stu3)


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

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originalPrescriptionfalseReference Original prescription if superceded by fulfiller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