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ExplanationOfBenefit

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

Properties

NameRequiredTypeDescription
identifierIdentifier[]

Business Identifier for the resource

Details

A unique identifier assigned to this explanation of benefit.

statuscode

active | cancelled | draft | entered-in-error

Details

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

typeCodeableConcept

Category or discipline

Details

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

subTypeCodeableConcept

More granular claim type

Details

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes such as the US UB-04 bill type code.

usecode

claim | preauthorization | predetermination

Details

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

patientReference<Patient>

The recipient of the products and services

Details

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

billablePeriodPeriod

Relevant time frame for the claim

Details

The period for which charges are being submitted.

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

createddateTime

Response creation date

Details

The date this resource was created.

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

entererReference<Practitioner | PractitionerRole>

Author of the claim

Details

Individual who created the claim, predetermination or preauthorization.

insurerReference<Organization>

Party responsible for reimbursement

Details

The party responsible for authorization, adjudication and reimbursement.

providerReference< Practitioner | PractitionerRole | Organization >

Party responsible for the claim

Details

The provider which is responsible for the claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

priorityCodeableConcept

Desired processing urgency

Details

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

fundsReserveRequestedCodeableConcept

For whom to reserve funds

Details

A code to indicate whether and for whom funds are to be reserved for future claims.

This field is only used for preauthorizations.

fundsReserveCodeableConcept

Funds reserved status

Details

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

relatedExplanationOfBenefitRelated[]

Prior or corollary claims

Details

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

For example, for the original treatment and follow-up exams.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

claimReference<Claim>

Reference to the related claim

Details

Reference to a related claim.

relationshipCodeableConcept

How the reference claim is related

Details

A code to convey how the claims are related.

For example, prior claim or umbrella.

referenceIdentifier

File or case reference

Details

An alternate organizational reference to the case or file to which this particular claim pertains.

For example, Property/Casualty insurer claim number or Workers Compensation case number.

prescriptionReference<MedicationRequest | VisionPrescription>

Prescription authorizing services or products

Details

Prescription to support the dispensing of pharmacy, device or vision products.

originalPrescriptionReference<MedicationRequest>

Original prescription if superceded by fulfiller

Details

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

payeeExplanationOfBenefitPayee

Recipient of benefits payable

Details

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

typeCodeableConcept

Category of recipient

Details

Type of Party to be reimbursed: Subscriber, provider, other.

partyReference< Practitioner | PractitionerRole | Organization | Patient | RelatedPerson >

Recipient reference

Details

Reference to the individual or organization to whom any payment will be made.

Not required if the payee is 'subscriber' or 'provider'.

referralReference<ServiceRequest>

Treatment Referral

Details

A reference to a referral resource.

The referral resource which lists the date, practitioner, reason and other supporting information.

facilityReference<Location>

Servicing Facility

Details

Facility where the services were provided.

claimReference<Claim>

Claim reference

Details

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

claimResponseReference<ClaimResponse>

Claim response reference

Details

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

outcomecode

queued | complete | error | partial

Details

The outcome of the claim, predetermination, or preauthorization processing.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

dispositionstring

Disposition Message

Details

A human readable description of the status of the adjudication.

preAuthRefstring[]

Preauthorization reference

Details

Reference from the Insurer which is used in later communications which refers to this adjudication.

This value is only present on preauthorization adjudications.

preAuthRefPeriodPeriod[]

Preauthorization in-effect period

Details

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

This value is only present on preauthorization adjudications.

careTeamExplanationOfBenefitCareTeam[]

Care Team members

Details

The members of the team who provided the products and services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Order of care team

Details

A number to uniquely identify care team entries.

providerReference< Practitioner | PractitionerRole | Organization >

Practitioner or organization

Details

Member of the team who provided the product or service.

responsibleboolean

Indicator of the lead practitioner

Details

The party who is billing and/or responsible for the claimed products or services.

Responsible might not be required when there is only a single provider listed.

roleCodeableConcept

Function within the team

Details

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Role might not be required when there is only a single provider listed.

qualificationCodeableConcept

Practitioner credential or specialization

Details

The qualification of the practitioner which is applicable for this service.

supportingInfoExplanationOfBenefitSupportingInfo[]

Supporting information

Details

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Often there are multiple jurisdiction specific valuesets which are required.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Information instance identifier

Details

A number to uniquely identify supporting information entries.

categoryCodeableConcept

Classification of the supplied information

Details

The general class of the information supplied: information; exception; accident, employment; onset, etc.

This may contain a category for the local bill type codes.

codeCodeableConcept

Type of information

Details

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

This may contain the local bill type codes such as the US UB-04 bill type code.

timing[x]date, Period

When it occurred

Details

The date when or period to which this information refers.

value[x]boolean, string, Quantity, Attachment, Reference<Resource>

Data to be provided

Details

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

reasonCoding

Explanation for the information

Details

Provides the reason in the situation where a reason code is required in addition to the content.

For example: the reason for the additional stay, or why a tooth is missing.

diagnosisExplanationOfBenefitDiagnosis[]

Pertinent diagnosis information

Details

Information about diagnoses relevant to the claim items.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Diagnosis instance identifier

Details

A number to uniquely identify diagnosis entries.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

diagnosis[x]CodeableConcept, Reference<Condition>

Nature of illness or problem

Details

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

typeCodeableConcept[]

Timing or nature of the diagnosis

Details

When the condition was observed or the relative ranking.

For example: admitting, primary, secondary, discharge.

onAdmissionCodeableConcept

Present on admission

Details

Indication of whether the diagnosis was present on admission to a facility.

packageCodeCodeableConcept

Package billing code

Details

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

procedureExplanationOfBenefitProcedure[]

Clinical procedures performed

Details

Procedures performed on the patient relevant to the billing items with the claim.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Procedure instance identifier

Details

A number to uniquely identify procedure entries.

typeCodeableConcept[]

Category of Procedure

Details

When the condition was observed or the relative ranking.

datedateTime

When the procedure was performed

Details

Date and optionally time the procedure was performed.

procedure[x]CodeableConcept, Reference<Procedure>

Specific clinical procedure

Details

The code or reference to a Procedure resource which identifies the clinical intervention performed.

udiReference<Device>[]

Unique device identifier

Details

Unique Device Identifiers associated with this line item.

precedencepositiveInt

Precedence (primary, secondary, etc.)

Details

This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.

insuranceExplanationOfBenefitInsurance[]

Patient insurance information

Details

Financial instruments for reimbursement for the health care products and services specified on the claim.

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

focalboolean

Coverage to be used for adjudication

Details

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

coverageReference<Coverage>

Insurance information

Details

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

preAuthRefstring[]

Prior authorization reference number

Details

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

accidentExplanationOfBenefitAccident

Details of the event

Details

Details of a accident which resulted in injuries which required the products and services listed in the claim.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

datedate

When the incident occurred

Details

Date of an accident event related to the products and services contained in the claim.

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

typeCodeableConcept

The nature of the accident

Details

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

location[x]Address, Reference<Location>

Where the event occurred

Details

The physical location of the accident event.

itemExplanationOfBenefitItem[]

Product or service provided

Details

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Item instance identifier

Details

A number to uniquely identify item entries.

careTeamSequencepositiveInt[]

Applicable care team members

Details

Care team members related to this service or product.

diagnosisSequencepositiveInt[]

Applicable diagnoses

Details

Diagnoses applicable for this service or product.

procedureSequencepositiveInt[]

Applicable procedures

Details

Procedures applicable for this service or product.

informationSequencepositiveInt[]

Applicable exception and supporting information

Details

Exceptions, special conditions and supporting information applicable for this service or product.

revenueCodeableConcept

Revenue or cost center code

Details

The type of revenue or cost center providing the product and/or service.

categoryCodeableConcept

Benefit classification

Details

Code to identify the general type of benefits under which products and services are provided.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Product or service billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

programCodeCodeableConcept[]

Program the product or service is provided under

Details

Identifies the program under which this may be recovered.

For example: Neonatal program, child dental program or drug users recovery program.

serviced[x]date, Period

Date or dates of service or product delivery

Details

The date or dates when the service or product was supplied, performed or completed.

location[x]CodeableConcept, Address, Reference<Location>

Place of service or where product was supplied

Details

Where the product or service was provided.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

udiReference<Device>[]

Unique device identifier

Details

Unique Device Identifiers associated with this line item.

bodySiteCodeableConcept

Anatomical location

Details

Physical service site on the patient (limb, tooth, etc.).

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

subSiteCodeableConcept[]

Anatomical sub-location

Details

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

encounterReference<Encounter>[]

Encounters related to this billed item

Details

A billed item may include goods or services provided in multiple encounters.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudicationExplanationOfBenefitItemAdjudication[]

Adjudication details

Details

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

categoryCodeableConcept

Type of adjudication information

Details

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

reasonCodeableConcept

Explanation of adjudication outcome

Details

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

For example, may indicate that the funds for this benefit type have been exhausted.

amountMoney

Monetary amount

Details

Monetary amount associated with the category.

For example, amount submitted, eligible amount, co-payment, and benefit payable.

valuedecimal

Non-monitary value

Details

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

For example: eligible percentage or co-payment percentage.

detailExplanationOfBenefitItemDetail[]

Additional items

Details

Second-tier of goods and services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Product or service provided

Details

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

revenueCodeableConcept

Revenue or cost center code

Details

The type of revenue or cost center providing the product and/or service.

categoryCodeableConcept

Benefit classification

Details

Code to identify the general type of benefits under which products and services are provided.

Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Service/Product billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

programCodeCodeableConcept[]

Program the product or service is provided under

Details

Identifies the program under which this may be recovered.

For example: Neonatal program, child dental program or drug users recovery program.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

udiReference<Device>[]

Unique device identifier

Details

Unique Device Identifiers associated with this line item.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Detail level adjudication details

Details

The adjudication results.

subDetailExplanationOfBenefitItemDetailSubDetail[]

Additional items

Details

Third-tier of goods and services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Product or service provided

Details

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

revenueCodeableConcept

Revenue or cost center code

Details

The type of revenue or cost center providing the product and/or service.

categoryCodeableConcept

Benefit classification

Details

Code to identify the general type of benefits under which products and services are provided.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Service/Product billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

programCodeCodeableConcept[]

Program the product or service is provided under

Details

Identifies the program under which this may be recovered.

For example: Neonatal program, child dental program or drug users recovery program.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

udiReference<Device>[]

Unique device identifier

Details

Unique Device Identifiers associated with this line item.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Subdetail level adjudication details

Details

The adjudication results.

addItemExplanationOfBenefitAddItem[]

Insurer added line items

Details

The first-tier service adjudications for payor added product or service lines.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

itemSequencepositiveInt[]

Item sequence number

Details

Claim items which this service line is intended to replace.

detailSequencepositiveInt[]

Detail sequence number

Details

The sequence number of the details within the claim item which this line is intended to replace.

subDetailSequencepositiveInt[]

Subdetail sequence number

Details

The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

providerReference< Practitioner | PractitionerRole | Organization >[]

Authorized providers

Details

The providers who are authorized for the services rendered to the patient.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Service/Product billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

programCodeCodeableConcept[]

Program the product or service is provided under

Details

Identifies the program under which this may be recovered.

For example: Neonatal program, child dental program or drug users recovery program.

serviced[x]date, Period

Date or dates of service or product delivery

Details

The date or dates when the service or product was supplied, performed or completed.

location[x]CodeableConcept, Address, Reference<Location>

Place of service or where product was supplied

Details

Where the product or service was provided.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

bodySiteCodeableConcept

Anatomical location

Details

Physical service site on the patient (limb, tooth, etc.).

For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

subSiteCodeableConcept[]

Anatomical sub-location

Details

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items adjudication

Details

The adjudication results.

detailExplanationOfBenefitAddItemDetail[]

Insurer added line items

Details

The second-tier service adjudications for payor added services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Service/Product billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items adjudication

Details

The adjudication results.

subDetailExplanationOfBenefitAddItemDetailSubDetail[]

Insurer added line items

Details

The third-tier service adjudications for payor added services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

modifierCodeableConcept[]

Service/Product billing modifiers

Details

Item typification or modifiers codes to convey additional context for the product or service.

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

factordecimal

Price scaling factor

Details

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

netMoney

Total item cost

Details

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items adjudication

Details

The adjudication results.

adjudication[]

Header-level adjudication

Details

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

totalExplanationOfBenefitTotal[]

Adjudication totals

Details

Categorized monetary totals for the adjudication.

Totals for amounts submitted, co-pays, benefits payable etc.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

categoryCodeableConcept

Type of adjudication information

Details

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

amountMoney

Financial total for the category

Details

Monetary total amount associated with the category.

paymentExplanationOfBenefitPayment

Payment Details

Details

Payment details for the adjudication of the claim.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

typeCodeableConcept

Partial or complete payment

Details

Whether this represents partial or complete payment of the benefits payable.

adjustmentMoney

Payment adjustment for non-claim issues

Details

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

adjustmentReasonCodeableConcept

Explanation for the variance

Details

Reason for the payment adjustment.

datedate

Expected date of payment

Details

Estimated date the payment will be issued or the actual issue date of payment.

amountMoney

Payable amount after adjustment

Details

Benefits payable less any payment adjustment.

identifierIdentifier

Business identifier for the payment

Details

Issuer's unique identifier for the payment instrument.

For example: EFT number or check number.

formCodeCodeableConcept

Printed form identifier

Details

A code for the form to be used for printing the content.

May be needed to identify specific jurisdictional forms.

formAttachment

Printed reference or actual form

Details

The actual form, by reference or inclusion, for printing the content or an EOB.

Needed to permit insurers to include the actual form.

processNoteExplanationOfBenefitProcessNote[]

Note concerning adjudication

Details

A note that describes or explains adjudication results in a human readable form.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

numberpositiveInt

Note instance identifier

Details

A number to uniquely identify a note entry.

typecode

display | print | printoper

Details

The business purpose of the note text.

textstring

Note explanatory text

Details

The explanation or description associated with the processing.

languageCodeableConcept

Language of the text

Details

A code to define the language used in the text of the note.

Only required if the language is different from the resource language.

benefitPeriodPeriod

When the benefits are applicable

Details

The term of the benefits documented in this response.

Not applicable when use=claim.

benefitBalanceExplanationOfBenefitBenefitBalance[]

Balance by Benefit Category

Details

Balance by Benefit Category.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

categoryCodeableConcept

Benefit classification

Details

Code to identify the general type of benefits under which products and services are provided.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

excludedboolean

Excluded from the plan

Details

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

namestring

Short name for the benefit

Details

A short name or tag for the benefit.

For example: MED01, or DENT2.

descriptionstring

Description of the benefit or services covered

Details

A richer description of the benefit or services covered.

For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

networkCodeableConcept

In or out of network

Details

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

unitCodeableConcept

Individual or family

Details

Indicates if the benefits apply to an individual or to the family.

termCodeableConcept

Annual or lifetime

Details

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

financialExplanationOfBenefitBenefitBalanceFinancial[]

Benefit Summary

Details

Benefits Used to date.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

typeCodeableConcept

Benefit classification

Details

Classification of benefit being provided.

For example: deductible, visits, benefit amount.

allowed[x]unsignedInt, string, Money

Benefits allowed

Details

The quantity of the benefit which is permitted under the coverage.

used[x]unsignedInt, Money

Benefits used

Details

The quantity of the benefit which have been consumed to date.

Search Parameters

NameTypeDescriptionExpression
care-teamreferenceMember of the CareTeamExplanationOfBenefit.careTeam.provider
claimreferenceThe reference to the claimExplanationOfBenefit.claim
coveragereferenceThe plan under which the claim was adjudicatedExplanationOfBenefit.insurance.coverage
createddateThe creation date for the EOBExplanationOfBenefit.created
detail-udireferenceUDI associated with a line item detail product or serviceExplanationOfBenefit.item.detail.udi
dispositionstringThe contents of the disposition messageExplanationOfBenefit.disposition
encounterreferenceEncounters associated with a billed line itemExplanationOfBenefit.item.encounter
entererreferenceThe party responsible for the entry of the ClaimExplanationOfBenefit.enterer
facilityreferenceFacility responsible for the goods and servicesExplanationOfBenefit.facility
identifiertokenThe business identifier of the Explanation of BenefitExplanationOfBenefit.identifier
item-udireferenceUDI associated with a line item product or serviceExplanationOfBenefit.item.udi
patientreferenceThe reference to the patientExplanationOfBenefit.patient
payeereferenceThe party receiving any payment for the ClaimExplanationOfBenefit.payee.party
procedure-udireferenceUDI associated with a procedureExplanationOfBenefit.procedure.udi
providerreferenceThe reference to the providerExplanationOfBenefit.provider
statustokenStatus of the instanceExplanationOfBenefit.status
subdetail-udireferenceUDI associated with a line item detail subdetail product or serviceExplanationOfBenefit.item.detail.subDetail.udi

Inherited Properties

NameRequiredTypeDescription
idstring

Logical id of this artifact

Details

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

metaMeta

Metadata about the resource

Details

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

implicitRulesuri

A set of rules under which this content was created

Details

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

languagecode

Language of the resource content

Details

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

textNarrative

Text summary of the resource, for human interpretation

Details

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

containedResource[]

Contained, inline Resources

Details

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored

Details

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.