explanation of benefits

Create Explanation Of Benefit

post
/organizations/{organizationId}/fhir/3/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.

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug

Body

resourceType*stringExplanationOfBenefitThis is a ExplanationOfBenefit resource
identifierarray(Identifier)The EOB Business Identifier.
statusstringactive|cancelled|draft|entered-in-errorThe status of the resource instance.
typeCodeableConceptThe category of claim, eg, oral, pharmacy, vision, insitutional, professional.
subTypearray(CodeableConcept)A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
patientReferencePatient Resource.
billablePeriodPeriodThe billable period for which charges are being submitted.
createdstringThe date when the EOB was created.
entererReferenceThe person who created the explanation of benefit.
insurerReferenceThe insurer which is responsible for the explanation of benefit.
providerReferenceThe provider which is responsible for the claim.
organizationReferenceThe provider which is responsible for the claim.
referralReferenceThe referral resource which lists the date, practitioner, reason and other supporting information.
facilityReferenceFacility where the services were provided.
claimReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
claimResponseReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
outcomeCodeableConceptProcessing outcome errror, partial or complete processing.
dispositionstringA description of the status of the adjudication.
relatedarray(ExplanationOfBenefit_Related)Other claims which are related to this claim such as prior claim versions or for related services.
prescriptionReferencePrescription to support the dispensing of Pharmacy or Vision products.
originalPrescriptionReferenceOriginal prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
payeeExplanationOfBenefit_PayeeThe party to be reimbursed for the services.
informationarray(ExplanationOfBenefit_Information)Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
careTeamarray(ExplanationOfBenefit_CareTeam)The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
diagnosisarray(ExplanationOfBenefit_Diagnosis)Ordered list of patient diagnosis for which care is sought.
procedurearray(ExplanationOfBenefit_Procedure)Ordered list of patient procedures performed to support the adjudication.
precedencenumberPrecedence (primary, secondary, etc.).
insuranceExplanationOfBenefit_InsuranceFinancial instrument by which payment information for health care.
accidentExplanationOfBenefit_AccidentAn accident which resulted in the need for healthcare services.
employmentImpactedPeriodThe start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
hospitalizationPeriodThe start and optional end dates of when the patient was confined to a treatment center.
itemarray(ExplanationOfBenefit_Item)First tier of goods and services.
addItemarray(ExplanationOfBenefit_AddItem)The first tier service adjudications for payor added services.
totalCostMoneyThe total cost of the services reported.
unallocDeductableMoneyThe amount of deductable applied which was not allocated to any particular service line.
totalBenefitMoneyTotal amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
paymentExplanationOfBenefit_PaymentPayment details for the claim if the claim has been paid.
formCodeableConceptThe form to be used for printing the content.
processNotearray(ExplanationOfBenefit_ProcessNote)Note text.
benefitBalancearray(ExplanationOfBenefit_BenefitBalance)Balance by Benefit Category.

Response

Patch Explanation Of Benefit

patch
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}

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*stringapplication/json-patch+jsonapplication/json-patch+json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug
resourceId*

Body

resourceType*stringExplanationOfBenefitThis is a ExplanationOfBenefit resource
identifierarray(Identifier)The EOB Business Identifier.
statusstringactive|cancelled|draft|entered-in-errorThe status of the resource instance.
typeCodeableConceptThe category of claim, eg, oral, pharmacy, vision, insitutional, professional.
subTypearray(CodeableConcept)A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
patientReferencePatient Resource.
billablePeriodPeriodThe billable period for which charges are being submitted.
createdstringThe date when the EOB was created.
entererReferenceThe person who created the explanation of benefit.
insurerReferenceThe insurer which is responsible for the explanation of benefit.
providerReferenceThe provider which is responsible for the claim.
organizationReferenceThe provider which is responsible for the claim.
referralReferenceThe referral resource which lists the date, practitioner, reason and other supporting information.
facilityReferenceFacility where the services were provided.
claimReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
claimResponseReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
outcomeCodeableConceptProcessing outcome errror, partial or complete processing.
dispositionstringA description of the status of the adjudication.
relatedarray(ExplanationOfBenefit_Related)Other claims which are related to this claim such as prior claim versions or for related services.
prescriptionReferencePrescription to support the dispensing of Pharmacy or Vision products.
originalPrescriptionReferenceOriginal prescription which has been superceded 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
payeeExplanationOfBenefit_PayeeThe party to be reimbursed for the services.
informationarray(ExplanationOfBenefit_Information)Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
careTeamarray(ExplanationOfBenefit_CareTeam)The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
diagnosisarray(ExplanationOfBenefit_Diagnosis)Ordered list of patient diagnosis for which care is sought.
procedurearray(ExplanationOfBenefit_Procedure)Ordered list of patient procedures performed to support the adjudication.
precedencenumberPrecedence (primary, secondary, etc.).
insuranceExplanationOfBenefit_InsuranceFinancial instrument by which payment information for health care.
accidentExplanationOfBenefit_AccidentAn accident which resulted in the need for healthcare services.
employmentImpactedPeriodThe start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
hospitalizationPeriodThe start and optional end dates of when the patient was confined to a treatment center.
itemarray(ExplanationOfBenefit_Item)First tier of goods and services.
addItemarray(ExplanationOfBenefit_AddItem)The first tier service adjudications for payor added services.
totalCostMoneyThe total cost of the services reported.
unallocDeductableMoneyThe amount of deductable applied which was not allocated to any particular service line.
totalBenefitMoneyTotal amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
paymentExplanationOfBenefit_PaymentPayment details for the claim if the claim has been paid.
formCodeableConceptThe form to be used for printing the content.
processNotearray(ExplanationOfBenefit_ProcessNote)Note text.
benefitBalancearray(ExplanationOfBenefit_BenefitBalance)Balance by Benefit Category.

Response

Read Explanation Of Benefit

get
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug
resourceId*

Response

Read History Explanation Of Benefit

get
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}/_history

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Query params

_countstring
_sincestring

Params

organizationId*string|stringid|slug
resourceId*

Response

Read Version Explanation Of Benefit

get
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}/_history/{versionId}

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug
resourceId*
versionId*

Response

Remove Explanation Of Benefit

delete
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug
resourceId*

Response

Search Get Explanation Of Benefit

get
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Query params

_idstring
_languagestring
care-teamstring
claimstring
coveragestring
createdstring
dispositionstring
encounterstring
entererstring
facilitystring
identifierstring
organizationstring
patientstring
payeestring
providerstring

Params

organizationId*string|stringid|slug

Response

Search History Explanation Of Benefit

get
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/_history

Request

Headers

content-type*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Query params

_countstring
_sincestring

Params

organizationId*string|stringid|slug

Response

Search Post Explanation Of Benefit

post
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/_search

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*stringapplication/json|application/x-www-form-urlencodedapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Query params

_idstring
_languagestring
care-teamstring
claimstring
coveragestring
createdstring
dispositionstring
encounterstring
entererstring
facilitystring
identifierstring
organizationstring
patientstring
payeestring
providerstring

Params

organizationId*string|stringid|slug

Body

resourceType*stringExplanationOfBenefitThis is a ExplanationOfBenefit resource
identifierarray(Identifier)The EOB Business Identifier.
statusstringactive|cancelled|draft|entered-in-errorThe status of the resource instance.
typeCodeableConceptThe category of claim, eg, oral, pharmacy, vision, insitutional, professional.
subTypearray(CodeableConcept)A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
patientReferencePatient Resource.
billablePeriodPeriodThe billable period for which charges are being submitted.
createdstringThe date when the EOB was created.
entererReferenceThe person who created the explanation of benefit.
insurerReferenceThe insurer which is responsible for the explanation of benefit.
providerReferenceThe provider which is responsible for the claim.
organizationReferenceThe provider which is responsible for the claim.
referralReferenceThe referral resource which lists the date, practitioner, reason and other supporting information.
facilityReferenceFacility where the services were provided.
claimReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
claimResponseReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
outcomeCodeableConceptProcessing outcome errror, partial or complete processing.
dispositionstringA description of the status of the adjudication.
relatedarray(ExplanationOfBenefit_Related)Other claims which are related to this claim such as prior claim versions or for related services.
prescriptionReferencePrescription to support the dispensing of Pharmacy or Vision products.
originalPrescriptionReferenceOriginal prescription which has been superceded 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
payeeExplanationOfBenefit_PayeeThe party to be reimbursed for the services.
informationarray(ExplanationOfBenefit_Information)Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
careTeamarray(ExplanationOfBenefit_CareTeam)The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
diagnosisarray(ExplanationOfBenefit_Diagnosis)Ordered list of patient diagnosis for which care is sought.
procedurearray(ExplanationOfBenefit_Procedure)Ordered list of patient procedures performed to support the adjudication.
precedencenumberPrecedence (primary, secondary, etc.).
insuranceExplanationOfBenefit_InsuranceFinancial instrument by which payment information for health care.
accidentExplanationOfBenefit_AccidentAn accident which resulted in the need for healthcare services.
employmentImpactedPeriodThe start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
hospitalizationPeriodThe start and optional end dates of when the patient was confined to a treatment center.
itemarray(ExplanationOfBenefit_Item)First tier of goods and services.
addItemarray(ExplanationOfBenefit_AddItem)The first tier service adjudications for payor added services.
totalCostMoneyThe total cost of the services reported.
unallocDeductableMoneyThe amount of deductable applied which was not allocated to any particular service line.
totalBenefitMoneyTotal amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
paymentExplanationOfBenefit_PaymentPayment details for the claim if the claim has been paid.
formCodeableConceptThe form to be used for printing the content.
processNotearray(ExplanationOfBenefit_ProcessNote)Note text.
benefitBalancearray(ExplanationOfBenefit_BenefitBalance)Balance by Benefit Category.

Response

Update Explanation Of Benefit

put
/organizations/{organizationId}/fhir/3/ExplanationOfBenefit/{resourceId}

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*stringapplication/jsonapplication/json
log-cdatastring
log-cdata-formatstringkv|jsonkv
AuthorizationstringBearer <token>

Params

organizationId*string|stringid|slug
resourceId*

Body

resourceType*stringExplanationOfBenefitThis is a ExplanationOfBenefit resource
identifierarray(Identifier)The EOB Business Identifier.
statusstringactive|cancelled|draft|entered-in-errorThe status of the resource instance.
typeCodeableConceptThe category of claim, eg, oral, pharmacy, vision, insitutional, professional.
subTypearray(CodeableConcept)A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
patientReferencePatient Resource.
billablePeriodPeriodThe billable period for which charges are being submitted.
createdstringThe date when the EOB was created.
entererReferenceThe person who created the explanation of benefit.
insurerReferenceThe insurer which is responsible for the explanation of benefit.
providerReferenceThe provider which is responsible for the claim.
organizationReferenceThe provider which is responsible for the claim.
referralReferenceThe referral resource which lists the date, practitioner, reason and other supporting information.
facilityReferenceFacility where the services were provided.
claimReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
claimResponseReferenceThe business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
outcomeCodeableConceptProcessing outcome errror, partial or complete processing.
dispositionstringA description of the status of the adjudication.
relatedarray(ExplanationOfBenefit_Related)Other claims which are related to this claim such as prior claim versions or for related services.
prescriptionReferencePrescription to support the dispensing of Pharmacy or Vision products.
originalPrescriptionReferenceOriginal prescription which has been superceded 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
payeeExplanationOfBenefit_PayeeThe party to be reimbursed for the services.
informationarray(ExplanationOfBenefit_Information)Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
careTeamarray(ExplanationOfBenefit_CareTeam)The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
diagnosisarray(ExplanationOfBenefit_Diagnosis)Ordered list of patient diagnosis for which care is sought.
procedurearray(ExplanationOfBenefit_Procedure)Ordered list of patient procedures performed to support the adjudication.
precedencenumberPrecedence (primary, secondary, etc.).
insuranceExplanationOfBenefit_InsuranceFinancial instrument by which payment information for health care.
accidentExplanationOfBenefit_AccidentAn accident which resulted in the need for healthcare services.
employmentImpactedPeriodThe start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
hospitalizationPeriodThe start and optional end dates of when the patient was confined to a treatment center.
itemarray(ExplanationOfBenefit_Item)First tier of goods and services.
addItemarray(ExplanationOfBenefit_AddItem)The first tier service adjudications for payor added services.
totalCostMoneyThe total cost of the services reported.
unallocDeductableMoneyThe amount of deductable applied which was not allocated to any particular service line.
totalBenefitMoneyTotal amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
paymentExplanationOfBenefit_PaymentPayment details for the claim if the claim has been paid.
formCodeableConceptThe form to be used for printing the content.
processNotearray(ExplanationOfBenefit_ProcessNote)Note text.
benefitBalancearray(ExplanationOfBenefit_BenefitBalance)Balance by Benefit Category.

Response