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type: resourceresource: ExplanationOfBenefit

ExplanationOfBenefit

Introduction

Scope and Usage

The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.

This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information in respect of a single payer prepared for consumption by the subscriber and/or patient. It is not simply a series of pointers to referred-to content models, is a physical subset scoped to the adjudication by a single payer which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.

Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. It may also be used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. An EOB will never be created for patient or subscriber information exchange if an error was detected in the Claim.

It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. When the resource was originally being developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource for multiple purposes.

Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if the payee is the provider as that would leak business confidential information.

Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. Only the ClaimResponse contains the appropriate adjudication information for a payer response to a Claim.

The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional Information

Additional information regarding electronic claims content and usage may be found at:

Boundaries and Relationships

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.

The eClaim domain includes a number of related resources

ExplanationOfBenefitThis resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payer proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
ClaimA suite of goods and services and insurances coverages under which adjudication or authorization is requested.
ClaimResponseA payer's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
CoverageEligibilityRequestA request to a payer to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.

Background and Context

Provides additional detail on exactly how the resource is to be used

Notes

Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an ._element_Sequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

The .noteNumber element, which appears at the .item, .detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumbers for each of the appropriate line items or details.

StructureDefinition

Elements (Simplified)

Mappings

Resource Packs

list-ExplanationOfBenefit-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="ExplanationOfBenefit-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

Full Search Parameters

Examples

Full Examples

Mapping Exceptions

explanationofbenefit-event-mapping-exceptions.xml

Divergent Elements

Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Unmapped Elements

explanationofbenefit-fivews-mapping-exceptions.xml

Unmapped Elements