ExplanationOfBenefit - FHIR Resource (r4)
This ExplanationOfBenefit Resource uses the FHIR API standard for access and structure.
Validate an ExplanationOfBenefit FHIR Resource (r4)
ExplanationOfBenefit Attributes
AttributeField is listTypeDescription
Description: Business Identifier for the resource
FHIR Version: r4
Attribute Type : Identifier
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
"value": "987654321"
}
]Learn more about the (ExplanationOfBenefit) identifier FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"status": "active"Learn more about the (ExplanationOfBenefit) status FHIR attribute
Description: Category or discipline
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
}Learn more about the (ExplanationOfBenefit) type FHIR attribute
Description: More granular claim type
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subType": Learn more about the (ExplanationOfBenefit) subType FHIR attribute
Description: claim | preauthorization | predetermination
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"use": "claim"Learn more about the (ExplanationOfBenefit) use FHIR attribute
Description: The recipient of the products and services
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"patient": {
"reference": "Patient/pat1"
}Learn more about the (ExplanationOfBenefit) patient FHIR attribute
Description: Relevant time frame for the claim
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"billablePeriod": Learn more about the (ExplanationOfBenefit) billablePeriod FHIR attribute
Description: Response creation date
FHIR Version: r4
Attribute Type : dateTime
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"created": "2014-08-16"Learn more about the (ExplanationOfBenefit) created FHIR attribute
Description: Author of the claim
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"enterer": {
"reference": "Practitioner/1"
}Learn more about the (ExplanationOfBenefit) enterer FHIR attribute
Description: Party responsible for reimbursement
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurer": {
"reference": "Organization/3"
}Learn more about the (ExplanationOfBenefit) insurer FHIR attribute
Description: Party responsible for the claim
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"provider": {
"reference": "Practitioner/1"
}Learn more about the (ExplanationOfBenefit) provider FHIR attribute
Description: Desired processing urgency
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"priority": Learn more about the (ExplanationOfBenefit) priority FHIR attribute
Description: For whom to reserve funds
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"fundsReserveRequested": Learn more about the (ExplanationOfBenefit) fundsReserveRequested FHIR attribute
Description: Funds reserved status
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"fundsReserve": Learn more about the (ExplanationOfBenefit) fundsReserve FHIR attribute
Description: Prior or corollary claims
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"related": Learn more about the (ExplanationOfBenefit) related FHIR attribute
Description: Prescription authorizing services or products
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"prescription": Learn more about the (ExplanationOfBenefit) prescription FHIR attribute
Description: Original prescription if superceded by fulfiller
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"originalPrescription": Learn more about the (ExplanationOfBenefit) originalPrescription FHIR attribute
Description: Recipient of benefits payable
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"party": {
"reference": "Organization/2"
}
}Learn more about the (ExplanationOfBenefit) payee FHIR attribute
Description: Treatment Referral
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"referral": Learn more about the (ExplanationOfBenefit) referral FHIR attribute
Description: Servicing Facility
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"facility": {
"reference": "Location/1"
}Learn more about the (ExplanationOfBenefit) facility FHIR attribute
Description: Reference to the related claim
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"claim": {
"reference": "Claim/100150"
}Learn more about the (ExplanationOfBenefit) claim FHIR attribute
Description: Claim response reference
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"claimResponse": {
"reference": "ClaimResponse/R3500"
}Learn more about the (ExplanationOfBenefit) claimResponse FHIR attribute
Description: queued | complete | error | partial
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"outcome": "complete"Learn more about the (ExplanationOfBenefit) outcome FHIR attribute
Description: Disposition Message
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"disposition": "Claim settled as per contract."Learn more about the (ExplanationOfBenefit) disposition FHIR attribute
Description: Preauthorization reference
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"preAuthRef": Learn more about the (ExplanationOfBenefit) preAuthRef FHIR attribute
Description: Preauthorization in-effect period
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"preAuthRefPeriod": Learn more about the (ExplanationOfBenefit) preAuthRefPeriod FHIR attribute
Description: Care Team members
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
]Learn more about the (ExplanationOfBenefit) careTeam FHIR attribute
Description: Supporting information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"supportingInfo": Learn more about the (ExplanationOfBenefit) supportingInfo FHIR attribute
Description: Pertinent diagnosis information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"diagnosis": Learn more about the (ExplanationOfBenefit) diagnosis FHIR attribute
Description: Clinical procedures performed
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"procedure": Learn more about the (ExplanationOfBenefit) procedure FHIR attribute
Description: Precedence (primary, secondary, etc.)
FHIR Version: r4
Attribute Type : positiveInt
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"precedence": Learn more about the (ExplanationOfBenefit) precedence FHIR attribute
Description: Patient insurance information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}
]Learn more about the (ExplanationOfBenefit) insurance FHIR attribute
Description: Details of the event
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"accident": Learn more about the (ExplanationOfBenefit) accident FHIR attribute
Description: Product or service provided
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code": "1205"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 135.57,
"currency": "USD"
},
"net": {
"value": 135.57,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"encounter": [
{
"reference": "Encounter/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 120,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 0.8
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 96,
"currency": "USD"
}
}
]
},
{
"sequence": 2,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"code": "group"
}
]
},
"servicedDate": "2014-08-16",
"net": {
"value": 200,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
],
"detail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"code": "group"
}
]
},
"net": {
"value": 200,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
],
"subDetail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code": "1205"
}
]
},
"unitPrice": {
"value": 200,
"currency": "USD"
},
"net": {
"value": 200,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 200,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 0.9
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
]
}
]
}
]
}
]Learn more about the (ExplanationOfBenefit) item FHIR attribute
Description: Insurer added line items
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"addItem": Learn more about the (ExplanationOfBenefit) addItem FHIR attribute
Description: Adjudication details
FHIR Version: r4
Attribute Type : See ExplanationOfBenefit.item.adjudication
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"adjudication": Learn more about the (ExplanationOfBenefit) adjudication FHIR attribute
Description: Adjudication totals
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 96,
"currency": "USD"
}
}
]Learn more about the (ExplanationOfBenefit) total FHIR attribute
Description: Payment Details
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payment": Learn more about the (ExplanationOfBenefit) payment FHIR attribute
Description: Printed form identifier
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"formCode": Learn more about the (ExplanationOfBenefit) formCode FHIR attribute
Description: Printed reference or actual form
FHIR Version: r4
Attribute Type : Attachment
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"form": Learn more about the (ExplanationOfBenefit) form FHIR attribute
Description: Note concerning adjudication
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"processNote": Learn more about the (ExplanationOfBenefit) processNote FHIR attribute
Description: When the benefits are applicable
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"benefitPeriod": Learn more about the (ExplanationOfBenefit) benefitPeriod FHIR attribute
Description: Balance by Benefit Category
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"benefitBalance": Learn more about the (ExplanationOfBenefit) benefitBalance FHIR attribute
ExplanationOfBenefit Example
{
"resourceType": "ExplanationOfBenefit",
"id": "EB3500",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
"value": "987654321"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/pat1"
},
"created": "2014-08-16",
"enterer": {
"reference": "Practitioner/1"
},
"insurer": {
"reference": "Organization/3"
},
"provider": {
"reference": "Practitioner/1"
},
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"party": {
"reference": "Organization/2"
}
},
"facility": {
"reference": "Location/1"
},
"claim": {
"reference": "Claim/100150"
},
"claimResponse": {
"reference": "ClaimResponse/R3500"
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code": "1205"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 135.57,
"currency": "USD"
},
"net": {
"value": 135.57,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"encounter": [
{
"reference": "Encounter/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 120,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 0.8
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 96,
"currency": "USD"
}
}
]
},
{
"sequence": 2,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"code": "group"
}
]
},
"servicedDate": "2014-08-16",
"net": {
"value": 200,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
],
"detail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"code": "group"
}
]
},
"net": {
"value": 200,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
],
"subDetail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code": "1205"
}
]
},
"unitPrice": {
"value": 200,
"currency": "USD"
},
"net": {
"value": 200,
"currency": "USD"
},
"udi": [
{
"reference": "Device/example"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 200,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 0.9
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 180,
"currency": "USD"
}
}
]
}
]
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 96,
"currency": "USD"
}
}
]
}ExplanationOfBenefit Structure
{
"resourceType" : "ExplanationOfBenefit",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // Business Identifier for the resource
"status" : "<code>", // R! active | cancelled | draft | entered-in-error
"type" : { CodeableConcept }, // R! Category or discipline
"subType" : { CodeableConcept }, // More granular claim type
"use" : "<code>", // R! claim | preauthorization | predetermination
"patient" : { Reference(Patient) }, // R! The recipient of the products and services
"billablePeriod" : { Period }, // Relevant time frame for the claim
"created" : "<dateTime>", // R! Response creation date
"enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim
"insurer" : { Reference(Organization) }, // R! Party responsible for reimbursement
"provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R! Party responsible for the claim
"priority" : { CodeableConcept }, // Desired processing urgency
"fundsReserveRequested" : { CodeableConcept }, // For whom to reserve funds
"fundsReserve" : { CodeableConcept }, // Funds reserved status
"related" : [{ // Prior or corollary claims
"claim" : { Reference(Claim) }, // Reference to the related claim
"relationship" : { CodeableConcept }, // How the reference claim is related
"reference" : { Identifier } // File or case reference
}],
"prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
"originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
"payee" : { // Recipient of benefits payable
"type" : { CodeableConcept }, // Category of recipient
"party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
RelatedPerson) } // Recipient reference
},
"referral" : { Reference(ServiceRequest) }, // Treatment Referral
"facility" : { Reference(Location) }, // Servicing Facility
"claim" : { Reference(Claim) }, // Claim reference
"claimResponse" : { Reference(ClaimResponse) }, // Claim response reference
"outcome" : "<code>", // R! queued | complete | error | partial
"disposition" : "<string>", // Disposition Message
"preAuthRef" : ["<string>"], // Preauthorization reference
"preAuthRefPeriod" : [{ Period }], // Preauthorization in-effect period
"careTeam" : [{ // Care Team members
"sequence" : "<positiveInt>", // R! Order of care team
"provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R! Practitioner or organization
"responsible" : <boolean>, // Indicator of the lead practitioner
"role" : { CodeableConcept }, // Function within the team
"qualification" : { CodeableConcept } // Practitioner credential or specialization
}],
"supportingInfo" : [{ // Supporting information
"sequence" : "<positiveInt>", // R! Information instance identifier
"category" : { CodeableConcept }, // R! Classification of the supplied information
"code" : { CodeableConcept }, // Type of information
// timing[x]: When it occurred. One of these 2:
"timingDate" : "<date>",
"timingPeriod" : { Period },
// value[x]: Data to be provided. One of these 5:
"valueBoolean" : <boolean>,
"valueString" : "<string>",
"valueQuantity" : { Quantity },
"valueAttachment" : { Attachment },
"valueReference" : { Reference(Any) },
"reason" : { Coding } // Explanation for the information
}],
"diagnosis" : [{ // Pertinent diagnosis information
"sequence" : "<positiveInt>", // R! Diagnosis instance identifier
// diagnosis[x]: Nature of illness or problem. One of these 2:
"diagnosisCodeableConcept" : { CodeableConcept },
"diagnosisReference" : { Reference(Condition) },
"type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
"onAdmission" : { CodeableConcept }, // Present on admission
"packageCode" : { CodeableConcept } // Package billing code
}],
"procedure" : [{ // Clinical procedures performed
"sequence" : "<positiveInt>", // R! Procedure instance identifier
"type" : [{ CodeableConcept }], // Category of Procedure
"date" : "<dateTime>", // When the procedure was performed
// procedure[x]: Specific clinical procedure. One of these 2:
"procedureCodeableConcept" : { CodeableConcept },
"procedureReference" : { Reference(Procedure) },
"udi" : [{ Reference(Device) }] // Unique device identifier
}],
"precedence" : "<positiveInt>", // Precedence (primary, secondary, etc.)
"insurance" : [{ // R! Patient insurance information
"focal" : <boolean>, // R! Coverage to be used for adjudication
"coverage" : { Reference(Coverage) }, // R! Insurance information
"preAuthRef" : ["<string>"] // Prior authorization reference number
}],
"accident" : { // Details of the event
"date" : "<date>", // When the incident occurred
"type" : { CodeableConcept }, // The nature of the accident
// location[x]: Where the event occurred. One of these 2:
"locationAddress" : { Address }
"locationReference" : { Reference(Location) }
},
"item" : [{ // Product or service provided
"sequence" : "<positiveInt>", // R! Item instance identifier
"careTeamSequence" : ["<positiveInt>"], // Applicable care team members
"diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
"procedureSequence" : ["<positiveInt>"], // Applicable procedures
"informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
"revenue" : { CodeableConcept }, // Revenue or cost center code
"category" : { CodeableConcept }, // Benefit classification
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Product or service billing modifiers
"programCode" : [{ CodeableConcept }], // Program the product or service is provided under
// serviced[x]: Date or dates of service or product delivery. One of these 2:
"servicedDate" : "<date>",
"servicedPeriod" : { Period },
// location[x]: Place of service or where product was supplied. 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 item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"udi" : [{ Reference(Device) }], // Unique device identifier
"bodySite" : { CodeableConcept }, // Anatomical location
"subSite" : [{ CodeableConcept }], // Anatomical sub-location
"encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ // Adjudication details
"category" : { CodeableConcept }, // R! Type of adjudication information
"reason" : { CodeableConcept }, // Explanation of adjudication outcome
"amount" : { Money }, // Monetary amount
"value" : <decimal> // Non-monitary value
}],
"detail" : [{ // Additional items
"sequence" : "<positiveInt>", // R! Product or service provided
"revenue" : { CodeableConcept }, // Revenue or cost center code
"category" : { CodeableConcept }, // Benefit classification
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"programCode" : [{ CodeableConcept }], // Program the product or service is provided under
"quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
"unitPrice" : { Money }, // Fee, charge or cost per item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"udi" : [{ Reference(Device) }], // Unique device identifier
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Detail level adjudication details
"subDetail" : [{ // Additional items
"sequence" : "<positiveInt>", // R! Product or service provided
"revenue" : { CodeableConcept }, // Revenue or cost center code
"category" : { CodeableConcept }, // Benefit classification
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"programCode" : [{ CodeableConcept }], // Program the product or service is provided under
"quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
"unitPrice" : { Money }, // Fee, charge or cost per item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"udi" : [{ Reference(Device) }], // Unique device identifier
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Subdetail level adjudication details
}]
}]
}],
"addItem" : [{ // Insurer added line items
"itemSequence" : ["<positiveInt>"], // Item sequence number
"detailSequence" : ["<positiveInt>"], // Detail sequence number
"subDetailSequence" : ["<positiveInt>"], // Subdetail sequence number
"provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"programCode" : [{ CodeableConcept }], // Program the product or service is provided under
// serviced[x]: Date or dates of service or product delivery. One of these 2:
"servicedDate" : "<date>",
"servicedPeriod" : { Period },
// location[x]: Place of service or where product was supplied. 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 item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"bodySite" : { CodeableConcept }, // Anatomical location
"subSite" : [{ CodeableConcept }], // Anatomical sub-location
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
"detail" : [{ // Insurer added line items
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
"unitPrice" : { Money }, // Fee, charge or cost per item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Added items adjudication
"subDetail" : [{ // Insurer added line items
"productOrService" : { CodeableConcept }, // R! Billing, service, product, or drug code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
"unitPrice" : { Money }, // Fee, charge or cost per item
"factor" : <decimal>, // Price scaling factor
"net" : { Money }, // Total item cost
"noteNumber" : ["<positiveInt>"], // Applicable note numbers
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }] // Added items adjudication
}]
}]
}],
"adjudication" : [{ Content as for ExplanationOfBenefit.item.adjudication }], // Header-level adjudication
"total" : [{ // Adjudication totals
"category" : { CodeableConcept }, // R! Type of adjudication information
"amount" : { Money } // R! Financial total for the category
}],
"payment" : { // Payment Details
"type" : { CodeableConcept }, // Partial or complete payment
"adjustment" : { Money }, // Payment adjustment for non-claim issues
"adjustmentReason" : { CodeableConcept }, // Explanation for the variance
"date" : "<date>", // Expected date of payment
"amount" : { Money }, // Payable amount after adjustment
"identifier" : { Identifier } // Business identifier for the payment
},
"formCode" : { CodeableConcept }, // Printed form identifier
"form" : { Attachment }, // Printed reference or actual form
"processNote" : [{ // Note concerning adjudication
"number" : "<positiveInt>", // Note instance identifier
"type" : "<code>", // display | print | printoper
"text" : "<string>", // Note explanatory text
"language" : { CodeableConcept } // Language of the text
}],
"benefitPeriod" : { Period }, // When the benefits are applicable
"benefitBalance" : [{ // Balance by Benefit Category
"category" : { CodeableConcept }, // R! Benefit classification
"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! Benefit classification
// 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 them like so:
https://api.1up.health/fhir/r4/ExplanationOfBenefit?query-param=queryvalue| Search Parameter | Field Type | Resource Fields Searched |
|---|---|---|
care-team | reference | careTeam.provider |
claim | reference | claim |
coverage | reference | insurance.coverage |
created | date | created |
detail-udi | reference | item.detail.udi |
disposition | text | disposition |
encounter | reference | item.encounter |
enterer | reference | enterer |
facility | reference | facility |
identifier | text | identifier |
item-udi | reference | item.udi |
patient | reference | patient |
payee | reference | payee.party |
procedure-udi | reference | procedure.udi |
provider | reference | provider |
status | text | status |
subdetail-udi | reference | item.detail.subDetail.udi |
