explanation of benefits
Create Explanation Of Benefit
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.
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug |
Body
resourceType* | This is a ExplanationOfBenefit resource | ||
id | id | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | |
meta | Meta | 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. | |
implicitRules | uri | 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. | |
language | code | The base language in which the resource is written. | |
text | Narrative | 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 | array(ResourceList) | 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. | |
extension | array(Extension) | 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. | |
modifierExtension | array(Extension) | 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). | |
identifier | array(Identifier) | A unique identifier assigned to this explanation of benefit. | |
status | active|cancelled|draft|entered-in-error | The status of the resource instance. | |
type* | CodeableConcept | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | |
subType | CodeableConcept | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |
use | code | 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. | |
patient* | Reference | 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. | |
billablePeriod | Period | The period for which charges are being submitted. | |
created | dateTime | The date this resource was created. | |
enterer | Reference | Individual who created the claim, predetermination or preauthorization. | |
insurer* | Reference | The party responsible for authorization, adjudication and reimbursement. | |
provider* | Reference | The provider which is responsible for the claim, predetermination or preauthorization. | |
priority | CodeableConcept | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | |
fundsReserveRequested | CodeableConcept | A code to indicate whether and for whom funds are to be reserved for future claims. | |
fundsReserve | CodeableConcept | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | |
related | array(ExplanationOfBenefit_Related) | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | |
prescription | Reference | Prescription to support the dispensing of pharmacy, device or vision products. | |
originalPrescription | Reference | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | |
payee | ExplanationOfBenefit_Payee | The party to be reimbursed for cost of the products and services according to the terms of the policy. | |
referral | Reference | A reference to a referral resource. | |
facility | Reference | Facility where the services were provided. | |
claim | Reference | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | |
claimResponse | Reference | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | |
outcome | code | The outcome of the claim, predetermination, or preauthorization processing. | |
disposition | string | A human readable description of the status of the adjudication. | |
preAuthRef | array(string) | Reference from the Insurer which is used in later communications which refers to this adjudication. | |
preAuthRefPeriod | array(Period) | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | |
careTeam | array(ExplanationOfBenefit_CareTeam) | The members of the team who provided the products and services. | |
supportingInfo | array(ExplanationOfBenefit_SupportingInfo) | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | |
diagnosis | array(ExplanationOfBenefit_Diagnosis) | Information about diagnoses relevant to the claim items. | |
procedure | array(ExplanationOfBenefit_Procedure) | Procedures performed on the patient relevant to the billing items with the claim. | |
precedence | positiveInt | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | |
insurance* | array(ExplanationOfBenefit_Insurance) | Financial instruments for reimbursement for the health care products and services specified on the claim. | |
accident | ExplanationOfBenefit_Accident | Details of a accident which resulted in injuries which required the products and services listed in the claim. | |
item | array(ExplanationOfBenefit_Item) | 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. | |
addItem | array(ExplanationOfBenefit_AddItem) | The first-tier service adjudications for payor added product or service lines. | |
adjudication | array(ExplanationOfBenefit_Adjudication) | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | |
total | array(ExplanationOfBenefit_Total) | Categorized monetary totals for the adjudication. | |
payment | ExplanationOfBenefit_Payment | Payment details for the adjudication of the claim. | |
formCode | CodeableConcept | A code for the form to be used for printing the content. | |
form | Attachment | The actual form, by reference or inclusion, for printing the content or an EOB. | |
processNote | array(ExplanationOfBenefit_ProcessNote) | A note that describes or explains adjudication results in a human readable form. | |
benefitPeriod | Period | The term of the benefits documented in this response. | |
benefitBalance | array(ExplanationOfBenefit_BenefitBalance) | Balance by Benefit Category. |
Response
Patch Explanation Of Benefit
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.
Request
Headers
content-type* | string | application/json-patch+json | application/json-patch+json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug | |
resourceId* |
Body
resourceType* | This is a ExplanationOfBenefit resource | ||
id | id | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | |
meta | Meta | 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. | |
implicitRules | uri | 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. | |
language | code | The base language in which the resource is written. | |
text | Narrative | 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 | array(ResourceList) | 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. | |
extension | array(Extension) | 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. | |
modifierExtension | array(Extension) | 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). | |
identifier | array(Identifier) | A unique identifier assigned to this explanation of benefit. | |
status | active|cancelled|draft|entered-in-error | The status of the resource instance. | |
type* | CodeableConcept | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | |
subType | CodeableConcept | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |
use | code | 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. | |
patient* | Reference | 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. | |
billablePeriod | Period | The period for which charges are being submitted. | |
created | dateTime | The date this resource was created. | |
enterer | Reference | Individual who created the claim, predetermination or preauthorization. | |
insurer* | Reference | The party responsible for authorization, adjudication and reimbursement. | |
provider* | Reference | The provider which is responsible for the claim, predetermination or preauthorization. | |
priority | CodeableConcept | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | |
fundsReserveRequested | CodeableConcept | A code to indicate whether and for whom funds are to be reserved for future claims. | |
fundsReserve | CodeableConcept | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | |
related | array(ExplanationOfBenefit_Related) | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | |
prescription | Reference | Prescription to support the dispensing of pharmacy, device or vision products. | |
originalPrescription | Reference | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | |
payee | ExplanationOfBenefit_Payee | The party to be reimbursed for cost of the products and services according to the terms of the policy. | |
referral | Reference | A reference to a referral resource. | |
facility | Reference | Facility where the services were provided. | |
claim | Reference | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | |
claimResponse | Reference | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | |
outcome | code | The outcome of the claim, predetermination, or preauthorization processing. | |
disposition | string | A human readable description of the status of the adjudication. | |
preAuthRef | array(string) | Reference from the Insurer which is used in later communications which refers to this adjudication. | |
preAuthRefPeriod | array(Period) | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | |
careTeam | array(ExplanationOfBenefit_CareTeam) | The members of the team who provided the products and services. | |
supportingInfo | array(ExplanationOfBenefit_SupportingInfo) | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | |
diagnosis | array(ExplanationOfBenefit_Diagnosis) | Information about diagnoses relevant to the claim items. | |
procedure | array(ExplanationOfBenefit_Procedure) | Procedures performed on the patient relevant to the billing items with the claim. | |
precedence | positiveInt | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | |
insurance* | array(ExplanationOfBenefit_Insurance) | Financial instruments for reimbursement for the health care products and services specified on the claim. | |
accident | ExplanationOfBenefit_Accident | Details of a accident which resulted in injuries which required the products and services listed in the claim. | |
item | array(ExplanationOfBenefit_Item) | 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. | |
addItem | array(ExplanationOfBenefit_AddItem) | The first-tier service adjudications for payor added product or service lines. | |
adjudication | array(ExplanationOfBenefit_Adjudication) | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | |
total | array(ExplanationOfBenefit_Total) | Categorized monetary totals for the adjudication. | |
payment | ExplanationOfBenefit_Payment | Payment details for the adjudication of the claim. | |
formCode | CodeableConcept | A code for the form to be used for printing the content. | |
form | Attachment | The actual form, by reference or inclusion, for printing the content or an EOB. | |
processNote | array(ExplanationOfBenefit_ProcessNote) | A note that describes or explains adjudication results in a human readable form. | |
benefitPeriod | Period | The term of the benefits documented in this response. | |
benefitBalance | array(ExplanationOfBenefit_BenefitBalance) | Balance by Benefit Category. |
Response
Read Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug | |
resourceId* |
Response
Read History Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Query params
_count | string | ||
_since | string |
Params
organizationId* | string|string | id|slug | |
resourceId* |
Response
Read Version Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug | |
resourceId* | |||
versionId* |
Response
Remove Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug | |
resourceId* |
Response
Search Get Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Query params
_id | string | ||
_language | string | ||
care-team | string | ||
claim | string | ||
coverage | string | ||
created | string | ||
detail-udi | string | ||
disposition | string | ||
encounter | string | ||
enterer | string | ||
facility | string | ||
identifier | string | ||
item-udi | string | ||
patient | string | ||
payee | string | ||
procedure-udi | string | ||
provider | string | ||
status | string | ||
subdetail-udi | string |
Params
organizationId* | string|string | id|slug |
Response
Search History Explanation Of Benefit
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Query params
_count | string | ||
_since | string |
Params
organizationId* | string|string | id|slug |
Response
Search Post Explanation Of Benefit
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.
Request
Headers
content-type* | string | application/json|application/x-www-form-urlencoded | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Query params
_id | string | ||
_language | string | ||
care-team | string | ||
claim | string | ||
coverage | string | ||
created | string | ||
detail-udi | string | ||
disposition | string | ||
encounter | string | ||
enterer | string | ||
facility | string | ||
identifier | string | ||
item-udi | string | ||
patient | string | ||
payee | string | ||
procedure-udi | string | ||
provider | string | ||
status | string | ||
subdetail-udi | string |
Params
organizationId* | string|string | id|slug |
Body
resourceType* | This is a ExplanationOfBenefit resource | ||
id | id | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | |
meta | Meta | 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. | |
implicitRules | uri | 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. | |
language | code | The base language in which the resource is written. | |
text | Narrative | 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 | array(ResourceList) | 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. | |
extension | array(Extension) | 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. | |
modifierExtension | array(Extension) | 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). | |
identifier | array(Identifier) | A unique identifier assigned to this explanation of benefit. | |
status | active|cancelled|draft|entered-in-error | The status of the resource instance. | |
type* | CodeableConcept | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | |
subType | CodeableConcept | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |
use | code | 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. | |
patient* | Reference | 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. | |
billablePeriod | Period | The period for which charges are being submitted. | |
created | dateTime | The date this resource was created. | |
enterer | Reference | Individual who created the claim, predetermination or preauthorization. | |
insurer* | Reference | The party responsible for authorization, adjudication and reimbursement. | |
provider* | Reference | The provider which is responsible for the claim, predetermination or preauthorization. | |
priority | CodeableConcept | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | |
fundsReserveRequested | CodeableConcept | A code to indicate whether and for whom funds are to be reserved for future claims. | |
fundsReserve | CodeableConcept | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | |
related | array(ExplanationOfBenefit_Related) | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | |
prescription | Reference | Prescription to support the dispensing of pharmacy, device or vision products. | |
originalPrescription | Reference | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | |
payee | ExplanationOfBenefit_Payee | The party to be reimbursed for cost of the products and services according to the terms of the policy. | |
referral | Reference | A reference to a referral resource. | |
facility | Reference | Facility where the services were provided. | |
claim | Reference | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | |
claimResponse | Reference | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | |
outcome | code | The outcome of the claim, predetermination, or preauthorization processing. | |
disposition | string | A human readable description of the status of the adjudication. | |
preAuthRef | array(string) | Reference from the Insurer which is used in later communications which refers to this adjudication. | |
preAuthRefPeriod | array(Period) | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | |
careTeam | array(ExplanationOfBenefit_CareTeam) | The members of the team who provided the products and services. | |
supportingInfo | array(ExplanationOfBenefit_SupportingInfo) | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | |
diagnosis | array(ExplanationOfBenefit_Diagnosis) | Information about diagnoses relevant to the claim items. | |
procedure | array(ExplanationOfBenefit_Procedure) | Procedures performed on the patient relevant to the billing items with the claim. | |
precedence | positiveInt | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | |
insurance* | array(ExplanationOfBenefit_Insurance) | Financial instruments for reimbursement for the health care products and services specified on the claim. | |
accident | ExplanationOfBenefit_Accident | Details of a accident which resulted in injuries which required the products and services listed in the claim. | |
item | array(ExplanationOfBenefit_Item) | 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. | |
addItem | array(ExplanationOfBenefit_AddItem) | The first-tier service adjudications for payor added product or service lines. | |
adjudication | array(ExplanationOfBenefit_Adjudication) | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | |
total | array(ExplanationOfBenefit_Total) | Categorized monetary totals for the adjudication. | |
payment | ExplanationOfBenefit_Payment | Payment details for the adjudication of the claim. | |
formCode | CodeableConcept | A code for the form to be used for printing the content. | |
form | Attachment | The actual form, by reference or inclusion, for printing the content or an EOB. | |
processNote | array(ExplanationOfBenefit_ProcessNote) | A note that describes or explains adjudication results in a human readable form. | |
benefitPeriod | Period | The term of the benefits documented in this response. | |
benefitBalance | array(ExplanationOfBenefit_BenefitBalance) | Balance by Benefit Category. |
Response
Update Explanation Of Benefit
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.
Request
Headers
content-type* | string | application/json|application/json+fhir | application/json |
log-cdata | string | ||
log-cdata-format | string | kv|json | kv |
Authorization | string | Bearer <token> |
Params
organizationId* | string|string | id|slug | |
resourceId* |
Body
resourceType* | This is a ExplanationOfBenefit resource | ||
id | id | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | |
meta | Meta | 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. | |
implicitRules | uri | 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. | |
language | code | The base language in which the resource is written. | |
text | Narrative | 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 | array(ResourceList) | 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. | |
extension | array(Extension) | 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. | |
modifierExtension | array(Extension) | 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). | |
identifier | array(Identifier) | A unique identifier assigned to this explanation of benefit. | |
status | active|cancelled|draft|entered-in-error | The status of the resource instance. | |
type* | CodeableConcept | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | |
subType | CodeableConcept | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |
use | code | 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. | |
patient* | Reference | 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. | |
billablePeriod | Period | The period for which charges are being submitted. | |
created | dateTime | The date this resource was created. | |
enterer | Reference | Individual who created the claim, predetermination or preauthorization. | |
insurer* | Reference | The party responsible for authorization, adjudication and reimbursement. | |
provider* | Reference | The provider which is responsible for the claim, predetermination or preauthorization. | |
priority | CodeableConcept | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | |
fundsReserveRequested | CodeableConcept | A code to indicate whether and for whom funds are to be reserved for future claims. | |
fundsReserve | CodeableConcept | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | |
related | array(ExplanationOfBenefit_Related) | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | |
prescription | Reference | Prescription to support the dispensing of pharmacy, device or vision products. | |
originalPrescription | Reference | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | |
payee | ExplanationOfBenefit_Payee | The party to be reimbursed for cost of the products and services according to the terms of the policy. | |
referral | Reference | A reference to a referral resource. | |
facility | Reference | Facility where the services were provided. | |
claim | Reference | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | |
claimResponse | Reference | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | |
outcome | code | The outcome of the claim, predetermination, or preauthorization processing. | |
disposition | string | A human readable description of the status of the adjudication. | |
preAuthRef | array(string) | Reference from the Insurer which is used in later communications which refers to this adjudication. | |
preAuthRefPeriod | array(Period) | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | |
careTeam | array(ExplanationOfBenefit_CareTeam) | The members of the team who provided the products and services. | |
supportingInfo | array(ExplanationOfBenefit_SupportingInfo) | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | |
diagnosis | array(ExplanationOfBenefit_Diagnosis) | Information about diagnoses relevant to the claim items. | |
procedure | array(ExplanationOfBenefit_Procedure) | Procedures performed on the patient relevant to the billing items with the claim. | |
precedence | positiveInt | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | |
insurance* | array(ExplanationOfBenefit_Insurance) | Financial instruments for reimbursement for the health care products and services specified on the claim. | |
accident | ExplanationOfBenefit_Accident | Details of a accident which resulted in injuries which required the products and services listed in the claim. | |
item | array(ExplanationOfBenefit_Item) | 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. | |
addItem | array(ExplanationOfBenefit_AddItem) | The first-tier service adjudications for payor added product or service lines. | |
adjudication | array(ExplanationOfBenefit_Adjudication) | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | |
total | array(ExplanationOfBenefit_Total) | Categorized monetary totals for the adjudication. | |
payment | ExplanationOfBenefit_Payment | Payment details for the adjudication of the claim. | |
formCode | CodeableConcept | A code for the form to be used for printing the content. | |
form | Attachment | The actual form, by reference or inclusion, for printing the content or an EOB. | |
processNote | array(ExplanationOfBenefit_ProcessNote) | A note that describes or explains adjudication results in a human readable form. | |
benefitPeriod | Period | The term of the benefits documented in this response. | |
benefitBalance | array(ExplanationOfBenefit_BenefitBalance) | Balance by Benefit Category. |