--- type: "resource" title: "ExplanationOfBenefit" resource: "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.](workflow#event) ### Additional Information Additional information regarding electronic claims content and usage may be found at: - [Financial Resource Status Lifecycle](financial-module#resource-status): how .status is used in the financial resources. - [Secondary Use of Resources](financial-module#secondary-use): how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payers. - [Subrogation](financial-module#subrogation): how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages. - [Coordination of Benefit](financial-module#cob): how eClaims may handle multiple patient insurance coverages. - [RealTime Exchange and Obtaining EOBs](financial-module#real-time): EOBs may be obtained using Polling or FHIR REST (SEARCH). - [Attachments and Supporting Information](financial-module#attachments): how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payer or later in a resource which refers to the subject eClaim resource. This also includes how payers may request additional supporting information from providers. - [3-Tier Line Item Hierarchy](financial-module#3-tier): 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing. - [Tax](financial-module#tax): Tax handling of Goods, products, and Services. ## 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](explanationofbenefit) should be used instead of the [Claim](claim) and [ClaimResponse](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](explanationofbenefit) should be used instead. The [Claim](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](coverageeligibilityrequest) should be used instead. **The eClaim domain includes a number of related resources** | ExplanationOfBenefit | This 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. | | --- | --- | | [Claim](claim) | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. | | [ClaimResponse](claimresponse) | A 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. | | [CoverageEligibilityRequest](coverageeligibilityrequest) | A 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 **.noteNumber**s for each of the appropriate line items or details. ## StructureDefinition ### Elements (Simplified) - **[ExplanationOfBenefit](/explanationofbenefit-definitions#ExplanationOfBenefit)** [0..*]: - Explanation of Benefit resource - **[ExplanationOfBenefit.identifier](/explanationofbenefit-definitions#ExplanationOfBenefit.identifier)** [0..*]: [Identifier](/Identifier) Business Identifier for the resource - **[ExplanationOfBenefit.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.status](/explanationofbenefit-definitions#ExplanationOfBenefit.status)** [1..1]: [code](/code) required:[explanationofbenefit-status](/valueset-explanationofbenefit-status) active | cancelled | draft | entered-in-error - **[ExplanationOfBenefit.statusReason](/explanationofbenefit-definitions#ExplanationOfBenefit.statusReason)** [0..1]: [string](/string) Reason for status change - **[ExplanationOfBenefit.type](/explanationofbenefit-definitions#ExplanationOfBenefit.type)** [1..1]: [CodeableConcept](/CodeableConcept) extensible:[claim-type](/valueset-claim-type) Category or discipline - **[ExplanationOfBenefit.subType](/explanationofbenefit-definitions#ExplanationOfBenefit.subType)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-subtype](/valueset-claim-subtype) More granular claim type - **[ExplanationOfBenefit.use](/explanationofbenefit-definitions#ExplanationOfBenefit.use)** [1..1]: [code](/code) required:[claim-use](/valueset-claim-use) claim | preauthorization | predetermination - **[ExplanationOfBenefit.subject](/explanationofbenefit-definitions#ExplanationOfBenefit.subject)** [1..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient(s) of the products and services - **[ExplanationOfBenefit.billablePeriod](/explanationofbenefit-definitions#ExplanationOfBenefit.billablePeriod)** [0..1]: [Period](/Period) Relevant time frame for the claim - **[ExplanationOfBenefit.created](/explanationofbenefit-definitions#ExplanationOfBenefit.created)** [1..1]: [dateTime](/dateTime) Response creation date - **[ExplanationOfBenefit.enterer](/explanationofbenefit-definitions#ExplanationOfBenefit.enterer)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Patient](/Patient), [RelatedPerson)](/RelatedPerson)) Author of the claim - **[ExplanationOfBenefit.insurer](/explanationofbenefit-definitions#ExplanationOfBenefit.insurer)** [0..1]: Reference([Organization](/Organization)) Party responsible for reimbursement - **[ExplanationOfBenefit.provider](/explanationofbenefit-definitions#ExplanationOfBenefit.provider)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Party responsible for the claim - **[ExplanationOfBenefit.priority](/explanationofbenefit-definitions#ExplanationOfBenefit.priority)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[process-priority](/valueset-process-priority) Desired processing urgency - **[ExplanationOfBenefit.fundsReserveRequested](/explanationofbenefit-definitions#ExplanationOfBenefit.fundsReserveRequested)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[fundsreserve](/valueset-fundsreserve) For whom to reserve funds - **[ExplanationOfBenefit.fundsReserve](/explanationofbenefit-definitions#ExplanationOfBenefit.fundsReserve)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[fundsreserve](/valueset-fundsreserve) Funds reserved status - **[ExplanationOfBenefit.related](/explanationofbenefit-definitions#ExplanationOfBenefit.related)** [0..*]: [BackboneElement](/BackboneElement) Prior or corollary claims - **[ExplanationOfBenefit.related.claim](/explanationofbenefit-definitions#ExplanationOfBenefit.related.claim)** [0..1]: [Reference(Claim](/Reference(Claim), [ExplanationOfBenefit)](/ExplanationOfBenefit)) Reference to the related claim - **[ExplanationOfBenefit.related.relationship](/explanationofbenefit-definitions#ExplanationOfBenefit.related.relationship)** [0..1]: [CodeableConcept](/CodeableConcept) example:[related-claim-relationship](/valueset-related-claim-relationship) How the reference claim is related - **[ExplanationOfBenefit.related.reference](/explanationofbenefit-definitions#ExplanationOfBenefit.related.reference)** [0..1]: [Identifier](/Identifier) File or case reference - **[ExplanationOfBenefit.prescription](/explanationofbenefit-definitions#ExplanationOfBenefit.prescription)** [0..1]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Prescription authorizing services or products - **[ExplanationOfBenefit.originalPrescription](/explanationofbenefit-definitions#ExplanationOfBenefit.originalPrescription)** [0..1]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Original prescription if superceded by fulfiller - **[ExplanationOfBenefit.event](/explanationofbenefit-definitions#ExplanationOfBenefit.event)** [0..*]: [BackboneElement](/BackboneElement) Event information - **[ExplanationOfBenefit.event.type](/explanationofbenefit-definitions#ExplanationOfBenefit.event.type)** [1..1]: [CodeableConcept](/CodeableConcept) example:[datestype](/valueset-datestype) Specific event - **[ExplanationOfBenefit.event.when[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.event.when%5Bx%5D)** [1..1]: [dateTime](/dateTime), [Period](/Period) Occurance date or period - **[ExplanationOfBenefit.payee](/explanationofbenefit-definitions#ExplanationOfBenefit.payee)** [0..1]: [BackboneElement](/BackboneElement) Recipient of benefits payable - **[ExplanationOfBenefit.payee.type](/explanationofbenefit-definitions#ExplanationOfBenefit.payee.type)** [0..1]: [CodeableConcept](/CodeableConcept) example:[payeetype](/valueset-payeetype) Category of recipient - **[ExplanationOfBenefit.payee.party](/explanationofbenefit-definitions#ExplanationOfBenefit.payee.party)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization), [Patient](/Patient), [RelatedPerson)](/RelatedPerson)) Recipient reference - **[ExplanationOfBenefit.referral](/explanationofbenefit-definitions#ExplanationOfBenefit.referral)** [0..1]: Reference([ServiceRequest](/ServiceRequest)) Treatment Referral - **[ExplanationOfBenefit.encounter](/explanationofbenefit-definitions#ExplanationOfBenefit.encounter)** [0..*]: Reference([Encounter](/Encounter)) Encounters associated with the listed treatments - **[ExplanationOfBenefit.facility](/explanationofbenefit-definitions#ExplanationOfBenefit.facility)** [0..1]: [Reference(Location](/Reference(Location), [Organization)](/Organization)) Servicing Facility - **[ExplanationOfBenefit.claim](/explanationofbenefit-definitions#ExplanationOfBenefit.claim)** [0..1]: Reference([Claim](/Claim)) Claim reference - **[ExplanationOfBenefit.claimResponse](/explanationofbenefit-definitions#ExplanationOfBenefit.claimResponse)** [0..1]: Reference([ClaimResponse](/ClaimResponse)) Claim response reference - **[ExplanationOfBenefit.outcome](/explanationofbenefit-definitions#ExplanationOfBenefit.outcome)** [1..1]: [code](/code) required:[claim-outcome](/valueset-claim-outcome) queued | complete | error | partial - **[ExplanationOfBenefit.decision](/explanationofbenefit-definitions#ExplanationOfBenefit.decision)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-decision](/valueset-claim-decision) Result of the adjudication - **[ExplanationOfBenefit.disposition](/explanationofbenefit-definitions#ExplanationOfBenefit.disposition)** [0..1]: [string](/string) Disposition Message - **[ExplanationOfBenefit.preAuthRef](/explanationofbenefit-definitions#ExplanationOfBenefit.preAuthRef)** [0..*]: [string](/string) Preauthorization reference - **[ExplanationOfBenefit.preAuthRefPeriod](/explanationofbenefit-definitions#ExplanationOfBenefit.preAuthRefPeriod)** [0..*]: [Period](/Period) Preauthorization in-effect period - **[ExplanationOfBenefit.diagnosisRelatedGroup](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosisRelatedGroup)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-diagnosisrelatedgroup](/valueset-ex-diagnosisrelatedgroup) Package billing code - **[ExplanationOfBenefit.careTeam](/explanationofbenefit-definitions#ExplanationOfBenefit.careTeam)** [0..*]: [BackboneElement](/BackboneElement) Care Team members - **[ExplanationOfBenefit.careTeam.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.careTeam.sequence)** [1..1]: [positiveInt](/positiveInt) Order of care team - **[ExplanationOfBenefit.careTeam.provider](/explanationofbenefit-definitions#ExplanationOfBenefit.careTeam.provider)** [1..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Practitioner or organization - **[ExplanationOfBenefit.careTeam.role](/explanationofbenefit-definitions#ExplanationOfBenefit.careTeam.role)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-careteamrole](/valueset-claim-careteamrole) Function within the team - **[ExplanationOfBenefit.careTeam.specialty](/explanationofbenefit-definitions#ExplanationOfBenefit.careTeam.specialty)** [0..1]: [CodeableConcept](/CodeableConcept) example:[provider-qualification](/valueset-provider-qualification) Practitioner or provider specialization - **[ExplanationOfBenefit.supportingInfo](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo)** [0..*]: [BackboneElement](/BackboneElement) Supporting information - **[ExplanationOfBenefit.supportingInfo.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.sequence)** [1..1]: [positiveInt](/positiveInt) Information instance identifier - **[ExplanationOfBenefit.supportingInfo.category](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.category)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-informationcategory](/valueset-claim-informationcategory) Classification of the supplied information - **[Claim.supportingInfo.subCategory](/explanationofbenefit-definitions#Claim.supportingInfo.subCategory)** [0..1]: [CodeableConcept](/CodeableConcept) Finer-grained classification of the supplied information - **[ExplanationOfBenefit.supportingInfo.code](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.code)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-exception](/valueset-claim-exception) Type of information - **[ExplanationOfBenefit.supportingInfo.timing[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.timing%5Bx%5D)** [0..1]: [dateTime](/dateTime), [Period](/Period), [Timing](/Timing) When it occurred - **[ExplanationOfBenefit.supportingInfo.value[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.value%5Bx%5D)** [0..1]: [*](/*) Data to be provided - **[ExplanationOfBenefit.supportingInfo.reason](/explanationofbenefit-definitions#ExplanationOfBenefit.supportingInfo.reason)** [0..1]: [Coding](/Coding) example:[missing-tooth-reason](/valueset-missing-tooth-reason) Explanation for the information - **[ExplanationOfBenefit.diagnosis](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosis)** [0..*]: [BackboneElement](/BackboneElement) Pertinent diagnosis information - **[ExplanationOfBenefit.diagnosis.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosis.sequence)** [1..1]: [positiveInt](/positiveInt) Diagnosis instance identifier - **[ExplanationOfBenefit.diagnosis.diagnosis[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosis.diagnosis%5Bx%5D)** [1..1]: [CodeableConcept](/CodeableConcept), Reference([Condition](/Condition)) example:[icd-10](/valueset-icd-10) Nature of illness or problem - **[ExplanationOfBenefit.diagnosis.type](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosis.type)** [0..*]: [CodeableConcept](/CodeableConcept) preferred:[ex-diagnosistype](/valueset-ex-diagnosistype) Timing or nature of the diagnosis - **[ExplanationOfBenefit.diagnosis.onAdmission](/explanationofbenefit-definitions#ExplanationOfBenefit.diagnosis.onAdmission)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[ex-diagnosis-on-admission](/valueset-ex-diagnosis-on-admission) Present on admission - **[ExplanationOfBenefit.procedure](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure)** [0..*]: [BackboneElement](/BackboneElement) Clinical procedures performed - **[ExplanationOfBenefit.procedure.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure.sequence)** [1..1]: [positiveInt](/positiveInt) Procedure instance identifier - **[ExplanationOfBenefit.procedure.type](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure.type)** [0..*]: [CodeableConcept](/CodeableConcept) preferred:[ex-procedure-type](/valueset-ex-procedure-type) Category of Procedure - **[ExplanationOfBenefit.procedure.date](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure.date)** [0..1]: [dateTime](/dateTime) When the procedure was performed - **[ExplanationOfBenefit.procedure.procedure[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure.procedure%5Bx%5D)** [1..1]: [CodeableConcept](/CodeableConcept), Reference([Procedure](/Procedure)) example:[icd-10-procedures](/valueset-icd-10-procedures) Specific clinical procedure - **[ExplanationOfBenefit.procedure.udi](/explanationofbenefit-definitions#ExplanationOfBenefit.procedure.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier - **[ExplanationOfBenefit.precedence](/explanationofbenefit-definitions#ExplanationOfBenefit.precedence)** [0..1]: [positiveInt](/positiveInt) Precedence (primary, secondary, etc.) - **[ExplanationOfBenefit.insurance](/explanationofbenefit-definitions#ExplanationOfBenefit.insurance)** [0..*]: [BackboneElement](/BackboneElement) Patient insurance information - **[ExplanationOfBenefit.insurance.focal](/explanationofbenefit-definitions#ExplanationOfBenefit.insurance.focal)** [1..1]: [boolean](/boolean) Coverage to be used for adjudication - **[ExplanationOfBenefit.insurance.coverage](/explanationofbenefit-definitions#ExplanationOfBenefit.insurance.coverage)** [1..1]: Reference([Coverage](/Coverage)) Insurance information - **[ExplanationOfBenefit.insurance.preAuthRef](/explanationofbenefit-definitions#ExplanationOfBenefit.insurance.preAuthRef)** [0..*]: [string](/string) Prior authorization reference number - **[ExplanationOfBenefit.accident](/explanationofbenefit-definitions#ExplanationOfBenefit.accident)** [0..1]: [BackboneElement](/BackboneElement) Details of the event - **[ExplanationOfBenefit.accident.date](/explanationofbenefit-definitions#ExplanationOfBenefit.accident.date)** [0..1]: [date](/date) When the incident occurred - **[ExplanationOfBenefit.accident.type](/explanationofbenefit-definitions#ExplanationOfBenefit.accident.type)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[v3-ActIncidentCode](/valueset-v3-ActIncidentCode) The nature of the accident - **[ExplanationOfBenefit.accident.location[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.accident.location%5Bx%5D)** [0..1]: [Address](/Address), Reference([Location](/Location)) Where the event occurred - **[ExplanationOfBenefit.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.item](/explanationofbenefit-definitions#ExplanationOfBenefit.item)** [0..*]: [BackboneElement](/BackboneElement) Product or service provided - **[ExplanationOfBenefit.item.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.sequence)** [1..1]: [positiveInt](/positiveInt) Item instance identifier - **[ExplanationOfBenefit.item.careTeamSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.careTeamSequence)** [0..*]: [positiveInt](/positiveInt) Applicable care team members - **[ExplanationOfBenefit.item.diagnosisSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.diagnosisSequence)** [0..*]: [positiveInt](/positiveInt) Applicable diagnoses - **[ExplanationOfBenefit.item.procedureSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.procedureSequence)** [0..*]: [positiveInt](/positiveInt) Applicable procedures - **[ExplanationOfBenefit.item.informationSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.informationSequence)** [0..*]: [positiveInt](/positiveInt) Applicable exception and supporting information - **[ExplanationOfBenefit.item.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.item.subject](/explanationofbenefit-definitions#ExplanationOfBenefit.item.subject)** [0..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient of the products and services - **[ExplanationOfBenefit.item.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.item.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.item.category](/explanationofbenefit-definitions#ExplanationOfBenefit.item.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ExplanationOfBenefit.item.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.item.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.item.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.item.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.item.request](/explanationofbenefit-definitions#ExplanationOfBenefit.item.request)** [0..*]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Request or Referral for Service - **[ExplanationOfBenefit.item.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.item.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Product or service billing modifiers - **[ExplanationOfBenefit.item.programCode](/explanationofbenefit-definitions#ExplanationOfBenefit.item.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under - **[ExplanationOfBenefit.item.serviced[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.item.serviced%5Bx%5D)** [0..1]: [date](/date), [Period](/Period) Date or dates of service or product delivery - **[ExplanationOfBenefit.item.location[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.item.location%5Bx%5D)** [0..1]: [CodeableConcept](/CodeableConcept), [Address](/Address), Reference([Location](/Location)) example:[service-place](/valueset-service-place) Place of service or where product was supplied - **[ExplanationOfBenefit.item.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.item.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.item.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.item.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.item.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.item.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.item.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.item.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.item.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.item.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.item.net](/explanationofbenefit-definitions#ExplanationOfBenefit.item.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.item.udi](/explanationofbenefit-definitions#ExplanationOfBenefit.item.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier - **[ExplanationOfBenefit.item.bodySite](/explanationofbenefit-definitions#ExplanationOfBenefit.item.bodySite)** [0..*]: [BackboneElement](/BackboneElement) Anatomical location - **[ExplanationOfBenefit.item.bodySite.site](/explanationofbenefit-definitions#ExplanationOfBenefit.item.bodySite.site)** [1..*]: [CodeableReference](/CodeableReference) example:[tooth](/valueset-tooth) Location - **[ExplanationOfBenefit.item.bodySite.subSite](/explanationofbenefit-definitions#ExplanationOfBenefit.item.bodySite.subSite)** [0..*]: [CodeableConcept](/CodeableConcept) example:[surface](/valueset-surface) Sub-location - **[ExplanationOfBenefit.item.encounter](/explanationofbenefit-definitions#ExplanationOfBenefit.item.encounter)** [0..*]: Reference([Encounter](/Encounter)) Encounters associated with the listed treatments - **[ExplanationOfBenefit.item.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.item.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.item.reviewOutcome)** [0..1]: [BackboneElement](/BackboneElement) Adjudication results - **[ExplanationOfBenefit.item.reviewOutcome.decision](/explanationofbenefit-definitions#ExplanationOfBenefit.item.reviewOutcome.decision)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-decision](/valueset-claim-decision) Result of the adjudication - **[ExplanationOfBenefit.item.reviewOutcome.reason](/explanationofbenefit-definitions#ExplanationOfBenefit.item.reviewOutcome.reason)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-decision-reason](/valueset-claim-decision-reason) Reason for result of the adjudication - **[ExplanationOfBenefit.item.reviewOutcome.preAuthRef](/explanationofbenefit-definitions#ExplanationOfBenefit.item.reviewOutcome.preAuthRef)** [0..1]: [string](/string) Preauthorization reference - **[ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod](/explanationofbenefit-definitions#ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod)** [0..1]: [Period](/Period) Preauthorization reference effective period - **[ExplanationOfBenefit.item.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication)** [0..*]: [BackboneElement](/BackboneElement) Adjudication details - **[ExplanationOfBenefit.item.adjudication.category](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication.category)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[adjudication](/valueset-adjudication) Type of adjudication information - **[ExplanationOfBenefit.item.adjudication.reason](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication.reason)** [0..1]: [CodeableConcept](/CodeableConcept) example:[adjudication-reason](/valueset-adjudication-reason) Explanation of adjudication outcome - **[ExplanationOfBenefit.item.adjudication.amount](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication.amount)** [0..1]: [Money](/Money) Monetary amount - **[ExplanationOfBenefit.item.adjudication.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication.quantity)** [0..1]: [Quantity](/Quantity) Non-monitary value - **[ExplanationOfBenefit.item.adjudication.decisionDate](/explanationofbenefit-definitions#ExplanationOfBenefit.item.adjudication.decisionDate)** [0..1]: [dateTime](/dateTime) When was adjudication performed - **[ExplanationOfBenefit.item.detail](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail)** [0..*]: [BackboneElement](/BackboneElement) Additional items - **[ExplanationOfBenefit.item.detail.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.sequence)** [1..1]: [positiveInt](/positiveInt) Product or service provided - **[ExplanationOfBenefit.item.detail.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.item.detail.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.item.detail.category](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ExplanationOfBenefit.item.detail.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.item.detail.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.item.detail.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ExplanationOfBenefit.item.detail.programCode](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under - **[ExplanationOfBenefit.item.detail.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.item.detail.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.item.detail.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.item.detail.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.item.detail.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.item.detail.net](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.item.detail.udi](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier - **[ExplanationOfBenefit.item.detail.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.item.detail.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.reviewOutcome)** [0..1]: - Detail level adjudication results - **[ExplanationOfBenefit.item.detail.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.adjudication)** [0..*]: - Detail level adjudication details - **[ExplanationOfBenefit.item.detail.subDetail](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail)** [0..*]: [BackboneElement](/BackboneElement) Additional items - **[ExplanationOfBenefit.item.detail.subDetail.sequence](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.sequence)** [1..1]: [positiveInt](/positiveInt) Product or service provided - **[ExplanationOfBenefit.item.detail.subDetail.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.item.detail.subDetail.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.item.detail.subDetail.category](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ExplanationOfBenefit.item.detail.subDetail.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.item.detail.subDetail.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ExplanationOfBenefit.item.detail.subDetail.programCode](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under - **[ExplanationOfBenefit.item.detail.subDetail.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.item.detail.subDetail.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.item.detail.subDetail.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.item.detail.subDetail.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.item.detail.subDetail.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.item.detail.subDetail.net](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.item.detail.subDetail.udi](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier - **[ExplanationOfBenefit.item.detail.subDetail.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.item.detail.subDetail.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.reviewOutcome)** [0..1]: - Subdetail level adjudication results - **[ExplanationOfBenefit.item.detail.subDetail.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.item.detail.subDetail.adjudication)** [0..*]: - Subdetail level adjudication details - **[ExplanationOfBenefit.addItem](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line items - **[ExplanationOfBenefit.addItem.itemSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.itemSequence)** [0..*]: [positiveInt](/positiveInt) Item sequence number - **[ExplanationOfBenefit.addItem.detailSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detailSequence)** [0..*]: [positiveInt](/positiveInt) Detail sequence number - **[ExplanationOfBenefit.addItem.subDetailSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.subDetailSequence)** [0..*]: [positiveInt](/positiveInt) Subdetail sequence number - **[ExplanationOfBenefit.addItem.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.addItem.subject](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.subject)** [0..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient of the products and services - **[ExplanationOfBenefit.addItem.informationSequence](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.informationSequence)** [0..*]: [positiveInt](/positiveInt) Applicable exception and supporting information - **[ExplanationOfBenefit.addItem.provider](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.provider)** [0..*]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Authorized providers - **[ExplanationOfBenefit.addItem.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.addItem.category](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ExplanationOfBenefit.addItem.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.addItem.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.addItem.request](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.request)** [0..*]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Request or Referral for Service - **[ExplanationOfBenefit.addItem.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ExplanationOfBenefit.addItem.programCode](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under - **[ExplanationOfBenefit.addItem.serviced[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.serviced%5Bx%5D)** [0..1]: [date](/date), [Period](/Period) Date or dates of service or product delivery - **[ExplanationOfBenefit.addItem.location[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.location%5Bx%5D)** [0..1]: [CodeableConcept](/CodeableConcept), [Address](/Address), Reference([Location](/Location)) example:[service-place](/valueset-service-place) Place of service or where product was supplied - **[ExplanationOfBenefit.addItem.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.addItem.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.addItem.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.addItem.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.addItem.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.addItem.net](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.addItem.bodySite](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.bodySite)** [0..*]: [BackboneElement](/BackboneElement) Anatomical location - **[ExplanationOfBenefit.addItem.bodySite.site](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.bodySite.site)** [1..*]: [CodeableReference](/CodeableReference) example:[tooth](/valueset-tooth) Location - **[ExplanationOfBenefit.addItem.bodySite.subSite](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.bodySite.subSite)** [0..*]: [CodeableConcept](/CodeableConcept) example:[surface](/valueset-surface) Sub-location - **[ExplanationOfBenefit.addItem.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.addItem.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.reviewOutcome)** [0..1]: - Additem level adjudication results - **[ExplanationOfBenefit.addItem.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.adjudication)** [0..*]: - Added items adjudication - **[ExplanationOfBenefit.addItem.detail](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line items - **[ExplanationOfBenefit.addItem.detail.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.addItem.detail.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.addItem.detail.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.addItem.detail.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.addItem.detail.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ExplanationOfBenefit.addItem.detail.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.addItem.detail.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.addItem.detail.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.addItem.detail.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.addItem.detail.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.addItem.detail.net](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.addItem.detail.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.addItem.detail.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.reviewOutcome)** [0..1]: - Additem detail level adjudication results - **[ExplanationOfBenefit.addItem.detail.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.adjudication)** [0..*]: - Added items adjudication - **[ExplanationOfBenefit.addItem.detail.subDetail](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line items - **[ExplanationOfBenefit.addItem.detail.subDetail.traceNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ExplanationOfBenefit.addItem.detail.subDetail.revenue](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ExplanationOfBenefit.addItem.detail.subDetail.productOrService](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ExplanationOfBenefit.addItem.detail.subDetail.modifier](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ExplanationOfBenefit.addItem.detail.subDetail.patientPaid](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient - **[ExplanationOfBenefit.addItem.detail.subDetail.quantity](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ExplanationOfBenefit.addItem.detail.subDetail.unitPrice](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ExplanationOfBenefit.addItem.detail.subDetail.factor](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ExplanationOfBenefit.addItem.detail.subDetail.tax](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.tax)** [0..1]: [Money](/Money) Total tax - **[ExplanationOfBenefit.addItem.detail.subDetail.net](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.net)** [0..1]: [Money](/Money) Total item cost - **[ExplanationOfBenefit.addItem.detail.subDetail.noteNumber](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome)** [0..1]: - Additem subdetail level adjudication results - **[ExplanationOfBenefit.addItem.detail.subDetail.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.addItem.detail.subDetail.adjudication)** [0..*]: - Added items adjudication - **[ExplanationOfBenefit.adjudication](/explanationofbenefit-definitions#ExplanationOfBenefit.adjudication)** [0..*]: - Header-level adjudication - **[ExplanationOfBenefit.total](/explanationofbenefit-definitions#ExplanationOfBenefit.total)** [0..*]: [BackboneElement](/BackboneElement) Adjudication totals - **[ExplanationOfBenefit.total.category](/explanationofbenefit-definitions#ExplanationOfBenefit.total.category)** [1..1]: [CodeableConcept](/CodeableConcept) example:[adjudication](/valueset-adjudication) Type of adjudication information - **[ExplanationOfBenefit.total.amount](/explanationofbenefit-definitions#ExplanationOfBenefit.total.amount)** [1..1]: [Money](/Money) Financial total for the category - **[ExplanationOfBenefit.payment](/explanationofbenefit-definitions#ExplanationOfBenefit.payment)** [0..1]: [BackboneElement](/BackboneElement) Payment Details - **[ExplanationOfBenefit.payment.type](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.type)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[ex-paymenttype](/valueset-ex-paymenttype) Partial or complete payment - **[ExplanationOfBenefit.payment.adjustment](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.adjustment)** [0..1]: [Money](/Money) Payment adjustment for non-claim issues - **[ExplanationOfBenefit.payment.adjustmentReason](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.adjustmentReason)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[payment-adjustment-reason](/valueset-payment-adjustment-reason) Explanation for the variance - **[ExplanationOfBenefit.payment.date](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.date)** [0..1]: [date](/date) Expected date of payment - **[ExplanationOfBenefit.payment.amount](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.amount)** [0..1]: [Money](/Money) Payable amount after adjustment - **[ExplanationOfBenefit.payment.identifier](/explanationofbenefit-definitions#ExplanationOfBenefit.payment.identifier)** [0..1]: [Identifier](/Identifier) Business identifier for the payment - **[ExplanationOfBenefit.formCode](/explanationofbenefit-definitions#ExplanationOfBenefit.formCode)** [0..1]: [CodeableConcept](/CodeableConcept) example:[forms](/valueset-forms) Printed form identifier - **[ExplanationOfBenefit.form](/explanationofbenefit-definitions#ExplanationOfBenefit.form)** [0..1]: [Attachment](/Attachment) Printed reference or actual form - **[ExplanationOfBenefit.processNote](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote)** [0..*]: [BackboneElement](/BackboneElement) Note concerning adjudication - **[ExplanationOfBenefit.processNote.class](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote.class)** [0..1]: [CodeableConcept](/CodeableConcept) Business kind of note - **[ExplanationOfBenefit.processNote.number](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote.number)** [0..1]: [positiveInt](/positiveInt) Note instance identifier - **[ExplanationOfBenefit.processNote.type](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote.type)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[note-type](/valueset-note-type) Note purpose - **[ExplanationOfBenefit.processNote.text](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote.text)** [0..1]: [markdown](/markdown) Note explanatory text - **[ExplanationOfBenefit.processNote.language](/explanationofbenefit-definitions#ExplanationOfBenefit.processNote.language)** [0..1]: [CodeableConcept](/CodeableConcept) required:[all-languages](/valueset-all-languages) Language of the text - **[ExplanationOfBenefit.benefitPeriod](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitPeriod)** [0..1]: [Period](/Period) When the benefits are applicable - **[ExplanationOfBenefit.benefitBalance](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance)** [0..*]: [BackboneElement](/BackboneElement) Balance by Benefit Category - **[ExplanationOfBenefit.benefitBalance.category](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.category)** [1..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ExplanationOfBenefit.benefitBalance.excluded](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.excluded)** [0..1]: [boolean](/boolean) Excluded from the plan - **[ExplanationOfBenefit.benefitBalance.name](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.name)** [0..1]: [string](/string) Short name for the benefit - **[ExplanationOfBenefit.benefitBalance.description](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.description)** [0..1]: [string](/string) Description of the benefit or services covered - **[ExplanationOfBenefit.benefitBalance.network](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.network)** [0..1]: [CodeableConcept](/CodeableConcept) example:[benefit-network](/valueset-benefit-network) In or out of network - **[ExplanationOfBenefit.benefitBalance.unit](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.unit)** [0..1]: [CodeableConcept](/CodeableConcept) example:[benefit-unit](/valueset-benefit-unit) Individual or family - **[ExplanationOfBenefit.benefitBalance.term](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.term)** [0..1]: [CodeableConcept](/CodeableConcept) example:[benefit-term](/valueset-benefit-term) Annual or lifetime - **[ExplanationOfBenefit.benefitBalance.financial](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.financial)** [0..*]: [BackboneElement](/BackboneElement) Benefit Summary - **[ExplanationOfBenefit.benefitBalance.financial.type](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.financial.type)** [1..1]: [CodeableConcept](/CodeableConcept) example:[benefit-type](/valueset-benefit-type) Benefit classification - **[ExplanationOfBenefit.benefitBalance.financial.allowed[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.financial.allowed%5Bx%5D)** [0..1]: [unsignedInt](/unsignedInt), [string](/string), [Money](/Money) Benefits allowed - **[ExplanationOfBenefit.benefitBalance.financial.used[x]](/explanationofbenefit-definitions#ExplanationOfBenefit.benefitBalance.financial.used%5Bx%5D)** [0..1]: [unsignedInt](/unsignedInt), [Money](/Money) Benefits used - **[ClaimResponse.error](/explanationofbenefit-definitions#ClaimResponse.error)** [0..*]: [BackboneElement](/BackboneElement) Processing errors - **[ClaimResponse.error.itemSequence](/explanationofbenefit-definitions#ClaimResponse.error.itemSequence)** [0..1]: [positiveInt](/positiveInt) Item sequence number - **[ClaimResponse.error.detailSequence](/explanationofbenefit-definitions#ClaimResponse.error.detailSequence)** [0..1]: [positiveInt](/positiveInt) Detail sequence number - **[ClaimResponse.error.subDetailSequence](/explanationofbenefit-definitions#ClaimResponse.error.subDetailSequence)** [0..1]: [positiveInt](/positiveInt) Subdetail sequence number - **[ClaimResponse.error.code](/explanationofbenefit-definitions#ClaimResponse.error.code)** [1..1]: [CodeableConcept](/CodeableConcept) example:[adjudication-error](/valueset-adjudication-error) Error code detailing processing issues - **[ExplanationOfBenefit.error.expression](/explanationofbenefit-definitions#ExplanationOfBenefit.error.expression)** [0..*]: [string](/string) FHIRPath of element(s) related to issue ## Mappings - [ExplanationOfBenefit Mappings](/explanationofbenefit-mappings) — 32 mapping entries ## Resource Packs ### list-ExplanationOfBenefit-packs.xml ```xml ``` ## Search Parameters - [care-team](/explanationofbenefit-search#care-team) — **reference** — Member of the CareTeam — `ExplanationOfBenefit.careTeam.provider` - [claim](/explanationofbenefit-search#claim) — **reference** — The reference to the claim — `ExplanationOfBenefit.claim` - [coverage](/explanationofbenefit-search#coverage) — **reference** — The plan under which the claim was adjudicated — `ExplanationOfBenefit.insurance.coverage` - [created](/explanationofbenefit-search#created) — **date** — The creation date for the EOB — `ExplanationOfBenefit.created` - [detail-udi](/explanationofbenefit-search#detail-udi) — **reference** — UDI associated with a line item detail product or service — `ExplanationOfBenefit.item.detail.udi` - [disposition](/explanationofbenefit-search#disposition) — **string** — The contents of the disposition message — `ExplanationOfBenefit.disposition` - [encounter](/explanationofbenefit-search#encounter) — **reference** — Encounters associated with a billed line item — `ExplanationOfBenefit.item.encounter` - [enterer](/explanationofbenefit-search#enterer) — **reference** — The party responsible for the entry of the Claim — `ExplanationOfBenefit.enterer` - [facility](/explanationofbenefit-search#facility) — **reference** — Facility responsible for the goods and services — `ExplanationOfBenefit.facility` - [group](/explanationofbenefit-search#group) — **reference** — The reference to the group — `ExplanationOfBenefit.subject.where(resolve() is Group) | ExplanationOfBenefit.item.subject.where(resolve() is Group) | ExplanationOfBenefit.addItem.subject.where(resolve() is Group)` - [identifier](/explanationofbenefit-search#identifier) — **token** — The business identifier of the Explanation of Benefit — `ExplanationOfBenefit.identifier` - [item-udi](/explanationofbenefit-search#item-udi) — **reference** — UDI associated with a line item product or service — `ExplanationOfBenefit.item.udi` - [patient](/explanationofbenefit-search#patient) — **reference** — The reference to the patient — `ExplanationOfBenefit.subject.where(resolve() is Patient) | ExplanationOfBenefit.item.subject.where(resolve() is Patient) | ExplanationOfBenefit.addItem.subject.where(resolve() is Patient)` - [payee](/explanationofbenefit-search#payee) — **reference** — The party receiving any payment for the Claim — `ExplanationOfBenefit.payee.party` - [subject](/explanationofbenefit-search#subject) — **reference** — Subject receiving the products or services — `ExplanationOfBenefit.subject | ExplanationOfBenefit.item.subject | ExplanationOfBenefit.addItem.subject` - [procedure-udi](/explanationofbenefit-search#procedure-udi) — **reference** — UDI associated with a procedure — `ExplanationOfBenefit.procedure.udi` - [provider](/explanationofbenefit-search#provider) — **reference** — The reference to the provider — `ExplanationOfBenefit.provider` - [status](/explanationofbenefit-search#status) — **token** — Status of the instance — `ExplanationOfBenefit.status` - [subdetail-udi](/explanationofbenefit-search#subdetail-udi) — **reference** — UDI associated with a line item detail subdetail product or service — `ExplanationOfBenefit.item.detail.subDetail.udi` [Full Search Parameters](/explanationofbenefit-search) ## Examples - [EB3500](/explanationofbenefit-example-EB3500) — explanationofbenefit-example — General Person Primary Coverage EOB Example - [EB3501](/explanationofbenefit-example-EB3501) — explanationofbenefit-example-2 — EOB for an Claim that had errors - [explanationofbenefit-example](/explanationofbenefit-example-explanationofbenefit-example) — explanationofbenefit-example - [explanationofbenefit-example-2](/explanationofbenefit-example-explanationofbenefit-example-2) — explanationofbenefit-example-2 - [explanationofbenefit-examples-header](/explanationofbenefit-example-explanationofbenefit-examples-header) — explanationofbenefit-examples-header [Full Examples](/explanationofbenefit-examples) ## Mapping Exceptions ### explanationofbenefit-event-mapping-exceptions.xml ### Divergent Elements - **Event.identifier** → **ExplanationOfBenefit.identifier** - summary | reason=Unknown | pattern=true - shortUnmatched | reason=Unknown | pattern=Business identifier for explanation of benefit | resource=Business Identifier for the resource - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this explanation of benefit by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=A unique identifier assigned to this explanation of benefit. - commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. - requirementsUnmatched | reason=Unknown | pattern=Allows identification of the explanation of benefit as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows EOBs to be distinguished and referenced. - **Event.status** → **ExplanationOfBenefit.status** - shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error - definitionUnmatched | reason=Unknown | pattern=The current state of the explanation of benefit. | resource=The status of the resource instance. - commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation 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. - **Event.code** → **ExplanationOfBenefit.type** - bindingStrength | reason=Unknown | pattern=example - shortUnmatched | reason=Unknown | pattern=What service was done | resource=Category or discipline - definitionUnmatched | reason=Unknown | pattern=A code that identifies the specific service or action that was or is being performed. | resource=The category of claim, e.g. oral, pharmacy, vision, institutional, professional. - **Event.subject** → **ExplanationOfBenefit.subject** - shortUnmatched | reason=Unknown | pattern=Individual service was done for/to | resource=The recipient(s) of the products and services - definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is being or was performed on. | resource=The party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. - requirementsUnmatched | reason=Unknown | pattern=Links the explanation of benefit to the Patient context. May also affect access control. | resource=The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. - **Event.occurrence[x]** → **ExplanationOfBenefit.created** - missingTypes | reason=Unknown | pattern=Period, Timing - shortUnmatched | reason=Unknown | pattern=When explanation of benefit occurred/is occurring | resource=Response creation date - definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the explanation of benefit did occur or is occurring. | resource=The date this resource was created. - commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. . ### Unmapped Elements - **Event.partOf** — Unknown - **Event.reported** — Unknown - **Event.reason** — Unknown - **Event.relevantHistory** — Unknown - **Event.location** — Unknown - **Event.statusReason** — Unknown - **Event.performer.actor** — Unknown - **Event.performer.function** — Unknown - **Event.note** — Unknown - **Event.category** — Unknown - **Event.encounter** — Unknown - **Event.recorded** — Unknown - **Event.product** — Unknown - **Event.performer** — Unknown - **Event.researchStudy** — Unknown ### explanationofbenefit-fivews-mapping-exceptions.xml ### Unmapped Elements - **FiveWs.what** — Unknown - **FiveWs.version** — Unknown - **FiveWs.witness** — Unknown - **FiveWs.context** — Unknown - **FiveWs.init** — Unknown - **FiveWs.who** — Unknown - **FiveWs.grade** — Unknown - **FiveWs.planned** — Unknown