ExplanationOfBenefit - FHIR Resource (stu3)
This ExplanationOfBenefit Resource uses the FHIR API standard for access and structure.
Validate an ExplanationOfBenefit FHIR Resource (stu3)
ExplanationOfBenefit Attributes
AttributeField is listTypeDescription
Description: Claim reference
FHIR Version: stu3
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: Precedence (primary, secondary, etc.)
FHIR Version: stu3
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: Servicing Facility
FHIR Version: stu3
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: Related Claims which may be revelant to processing this claim
FHIR Version: stu3
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Description: Original prescription if superceded by fulfiller
FHIR Version: stu3
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: Claim response reference
FHIR Version: stu3
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: Period for charge submission
FHIR Version: stu3
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: Processing notes
FHIR Version: stu3
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: Insurance or medical plan
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurance": {
"coverage": {
"reference": "Coverage/9876B1"
}
}Learn more about the (ExplanationOfBenefit) insurance FHIR attribute
Description: Total Cost of service from the Claim
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"totalCost": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 135.57
}Learn more about the (ExplanationOfBenefit) totalCost FHIR attribute
Description: Exceptions, special considerations, the condition, situation, prior or concurrent issues
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"information": Learn more about the (ExplanationOfBenefit) information FHIR attribute
Description: Party to be paid any benefits payable
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
]
}
}Learn more about the (ExplanationOfBenefit) payee FHIR attribute
Description: Author
FHIR Version: stu3
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: Responsible provider for the claim
FHIR Version: stu3
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: Type or discipline
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"code": "oral",
"system": "http://hl7.org/fhir/ex-claimtype"
}
]
}Learn more about the (ExplanationOfBenefit) type FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: stu3
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: Balance by Benefit Category
FHIR Version: stu3
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
Description: The subject of the Products and Services
FHIR Version: stu3
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: Period in hospital
FHIR Version: stu3
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"hospitalization": Learn more about the (ExplanationOfBenefit) hospitalization FHIR attribute
Description: Printed Form Identifier
FHIR Version: stu3
Attribute Type : CodeableConcept
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: Insurer responsible for the EOB
FHIR Version: stu3
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurer": Learn more about the (ExplanationOfBenefit) insurer FHIR attribute
Description: Insurer added line items
FHIR Version: stu3
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: complete | error | partial
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"outcome": {
"coding": [
{
"code": "complete",
"system": "http://hl7.org/fhir/remittance-outcome"
}
]
}Learn more about the (ExplanationOfBenefit) outcome FHIR attribute
Description: Disposition Message
FHIR Version: stu3
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: Payment (if paid)
FHIR Version: stu3
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: Period unable to work
FHIR Version: stu3
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"employmentImpacted": Learn more about the (ExplanationOfBenefit) employmentImpacted FHIR attribute
Description: Details of an accident
FHIR Version: stu3
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: Prescription authorizing services or products
FHIR Version: stu3
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: Treatment Referral
FHIR Version: stu3
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: Creation date
FHIR Version: stu3
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: Total benefit payable for the Claim
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"totalBenefit": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 96
}Learn more about the (ExplanationOfBenefit) totalBenefit FHIR attribute
Description: Unallocated deductable
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"unallocDeductable": Learn more about the (ExplanationOfBenefit) unallocDeductable FHIR attribute
Description: Goods and Services
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
]
}
]Learn more about the (ExplanationOfBenefit) item FHIR attribute
Description: Finer grained claim type information
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subType": Learn more about the (ExplanationOfBenefit) subType FHIR attribute
Description: List of Diagnosis
FHIR Version: stu3
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: Care Team members
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"careTeam": [
{
"provider": {
"reference": "Practitioner/example"
},
"sequence": 1
}
]Learn more about the (ExplanationOfBenefit) careTeam FHIR attribute
Description: Responsible organization for the claim
FHIR Version: stu3
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"organization": {
"reference": "Organization/2"
}Learn more about the (ExplanationOfBenefit) organization FHIR attribute
Description: Business Identifier
FHIR Version: stu3
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: Procedures performed
FHIR Version: stu3
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
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 them like so:
https://api.1up.health/fhir/stu3/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 |
disposition | text | disposition |
encounter | reference | item.encounter |
enterer | reference | enterer |
facility | reference | facility |
identifier | text | identifier |
organization | reference | organization |
patient | reference | patient |
payee | reference | payee.party |
provider | reference | provider |
