type: resource-definitionsresource: ExplanationOfBenefit

ExplanationOfBenefit Definitions

ExplanationOfBenefit

Explanation of Benefit resource

Definition: 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.

Aliases: EOB

Cardinality: 0..*

Mappings: workflow=Event; w5=financial.other

ExplanationOfBenefit.identifier

Business Identifier for the resource

Definition: A unique identifier assigned to this explanation of benefit.

Requirements: Allows EOBs to be distinguished and referenced.

Cardinality: 0..*

Type: Identifier

Mappings: workflow=Event.identifier; w5=FiveWs.identifier

ExplanationOfBenefit.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.status

active | cancelled | draft | entered-in-error

Definition: The status of the resource instance.

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

Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Cardinality: 1..1

Type: code

Binding: required:explanationofbenefit-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status

ExplanationOfBenefit.statusReason

Reason for status change

Definition: Used to indicate why the status has changed.

Comments: Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

Requirements: This is used to implement conformance on other elements.

Cardinality: 0..1

Type: string

Summary: true

ExplanationOfBenefit.type

Category or discipline

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

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

Requirements: Claim type determine the general sets of business rules applied for information requirements and adjudication.

Cardinality: 1..1

Type: CodeableConcept

Binding: extensible:claim-type

Summary: true

Mappings: workflow=Event.code; w5=FiveWs.class

ExplanationOfBenefit.subType

More granular claim type

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

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

Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-subtype

Mappings: w5=FiveWs.class

ExplanationOfBenefit.use

claim | preauthorization | predetermination

Definition: A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.

Requirements: This element is required to understand the nature of the request for adjudication.

Cardinality: 1..1

Type: code

Binding: required:claim-use

Summary: true

Mappings: w5=FiveWs.class

ExplanationOfBenefit.subject

The recipient(s) of the products and services

Definition: 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.

Requirements: 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.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject

ExplanationOfBenefit.billablePeriod

Relevant time frame for the claim

Definition: The period for which charges are being submitted.

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

Requirements: A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Cardinality: 0..1

Type: Period

Summary: true

Mappings: w5=FiveWs.done[x]

ExplanationOfBenefit.created

Response creation date

Definition: The date this resource was created.

Requirements: Need to record a timestamp for use by both the recipient and the issuer.

Cardinality: 1..1

Type: dateTime

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.recorded

ExplanationOfBenefit.enterer

Author of the claim

Definition: Individual who created the claim, predetermination or preauthorization.

Requirements: Some jurisdictions require the contact information for personnel completing claims.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Patient, RelatedPerson)

Mappings: workflow=Event.performer.agent; w5=FiveWs.author

ExplanationOfBenefit.insurer

Party responsible for reimbursement

Definition: The party responsible for authorization, adjudication and reimbursement.

Requirements: To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

Mappings: workflow=Event.performer.agent; w5=FiveWs.author

ExplanationOfBenefit.provider

Party responsible for the claim

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

Comments: Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Summary: true

Mappings: w5=FiveWs.source

ExplanationOfBenefit.priority

Desired processing urgency

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

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

Requirements: The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:process-priority

Mappings: v2=Request.priority

ExplanationOfBenefit.fundsReserveRequested

For whom to reserve funds

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

Comments: This field is only used for preauthorizations.

Requirements: In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Aliases: Fund pre-allocation

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:fundsreserve

ExplanationOfBenefit.fundsReserve

Funds reserved status

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

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

Requirements: Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:fundsreserve

ExplanationOfBenefit.related

Prior or corollary claims

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

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

Requirements: For workplace or other accidents it is common to relate separate claims arising from the same event.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.related.claim

Reference to the related claim

Definition: Reference to a related Claim or ExplanationOfBenefit as a representation of a claim.

Requirements: For workplace or other accidents it is common to relate separate claims arising from the same event.

Cardinality: 0..1

Type: Reference(Claim, ExplanationOfBenefit)

ExplanationOfBenefit.related.relationship

How the reference claim is related

Definition: A code to convey how the claims are related.

Comments: For example, prior claim or umbrella.

Requirements: Some insurers need a declaration of the type of relationship.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:related-claim-relationship

ExplanationOfBenefit.related.reference

File or case reference

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

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

Requirements: In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Cardinality: 0..1

Type: Identifier

ExplanationOfBenefit.prescription

Prescription authorizing services or products

Definition: Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.

Requirements: Required to authorize the dispensing of controlled substances and devices.

Cardinality: 0..1

Type: Reference(DeviceRequest, MedicationRequest, ServiceRequest, VisionPrescription)

ExplanationOfBenefit.originalPrescription

Original prescription if superceded by fulfiller

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

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

Requirements: Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Cardinality: 0..1

Type: Reference(DeviceRequest, MedicationRequest, ServiceRequest, VisionPrescription)

ExplanationOfBenefit.event

Event information

Definition: Information code for an event with a corresponding date or period.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.event.type

Specific event

Definition: A coded event such as when a service is expected or a card printed.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:datestype

ExplanationOfBenefit.event.when[x]

Occurance date or period

Definition: A date or period in the past or future indicating when the event occurred or is expectd to occur.

Cardinality: 1..1

Type: dateTime, Period

ExplanationOfBenefit.payee

Recipient of benefits payable

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

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

Requirements: The billing provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Cardinality: 0..1

Type: BackboneElement

ExplanationOfBenefit.payee.type

Category of recipient

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

Requirements: Need to know who should receive payment with the most common situations being the billing Provider (assignment of benefits) or the Subscriber.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:payeetype

ExplanationOfBenefit.payee.party

Recipient reference

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

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

Requirements: Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)

ExplanationOfBenefit.referral

Treatment Referral

Definition: The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.

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

Requirements: Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Cardinality: 0..1

Type: Reference(ServiceRequest)

Mappings: w5=FiveWs.cause

ExplanationOfBenefit.encounter

Encounters associated with the listed treatments

Definition: Healthcare encounters related to this claim.

Requirements: Used in some jurisdictions to link clinical events to claim items.

Cardinality: 0..*

Type: Reference(Encounter)

ExplanationOfBenefit.facility

Servicing Facility

Definition: Facility where the services were provided.

Requirements: Insurance adjudication can be dependant on where services were delivered.

Cardinality: 0..1

Type: Reference(Location, Organization)

Mappings: workflow=Event.performer.location; w5=FiveWs.where[x]

ExplanationOfBenefit.claim

Claim reference

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

Requirements: To provide a link to the original adjudication request.

Cardinality: 0..1

Type: Reference(Claim)

Mappings: w5=FiveWs.why[x]

ExplanationOfBenefit.claimResponse

Claim response reference

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

Requirements: To provide a link to the original adjudication response.

Cardinality: 0..1

Type: Reference(ClaimResponse)

ExplanationOfBenefit.outcome

queued | complete | error | partial

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

Comments: The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).

Requirements: To advise the requestor of an overall processing outcome.

Cardinality: 1..1

Type: code

Binding: required:claim-outcome

Summary: true

ExplanationOfBenefit.decision

Result of the adjudication

Definition: The result of the claim, predetermination, or preauthorization adjudication.

Comments: The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).

Requirements: To advise the requestor of the result of the adjudication process.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-decision

Summary: true

ExplanationOfBenefit.disposition

Disposition Message

Definition: A human readable description of the status of the adjudication.

Requirements: Provided for user display.

Cardinality: 0..1

Type: string

ExplanationOfBenefit.preAuthRef

Preauthorization reference

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

Comments: This value is only present on preauthorization adjudications.

Requirements: On subsequent claims, the insurer may require the provider to quote this value.

Cardinality: 0..*

Type: string

ExplanationOfBenefit.preAuthRefPeriod

Preauthorization in-effect period

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

Comments: This value is only present on preauthorization adjudications.

Requirements: On subsequent claims, the insurer may require the provider to quote this value.

Cardinality: 0..*

Type: Period

ExplanationOfBenefit.diagnosisRelatedGroup

Package billing code

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

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

Requirements: Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-diagnosisrelatedgroup

ExplanationOfBenefit.careTeam

Care Team members

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

Requirements: Common to identify the responsible and supporting practitioners.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.careTeam.sequence

Order of care team

Definition: A number to uniquely identify care team entries.

Requirements: Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.careTeam.provider

Practitioner or organization

Definition: Member of the team who provided the product or service.

Requirements: Often a regulatory requirement to specify the responsible provider.

Cardinality: 1..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.actor

ExplanationOfBenefit.careTeam.role

Function within the team

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

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

Requirements: When multiple parties are present it is required to distinguish the roles performed by each member.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-careteamrole

ExplanationOfBenefit.careTeam.specialty

Practitioner or provider specialization

Definition: The specialization of the practitioner or provider which is applicable for this service.

Requirements: Need to specify which specialization a practitioner or provider acting under when delivering the product or service.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:provider-qualification

ExplanationOfBenefit.supportingInfo

Supporting information

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

Comments: Often there are multiple jurisdiction specific valuesets which are required.

Requirements: Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.supportingInfo.sequence

Information instance identifier

Definition: A number to uniquely identify supporting information entries.

Requirements: Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.supportingInfo.category

Classification of the supplied information

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

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

Requirements: Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:claim-informationcategory

Claim.supportingInfo.subCategory

Finer-grained classification of the supplied information

Definition: A finer classification within the more general category.

Requirements: Required to provide more detailed categorization, for example lab-test grouping: blood, tissue etc.

Cardinality: 0..1

Type: CodeableConcept

Binding: example

ExplanationOfBenefit.supportingInfo.code

Type of information

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

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

Requirements: Required to identify the kind of additional information.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-exception

ExplanationOfBenefit.supportingInfo.timing[x]

When it occurred

Definition: The date when or period to which this information refers.

Cardinality: 0..1

Type: dateTime, Period, Timing

ExplanationOfBenefit.supportingInfo.value[x]

Data to be provided

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

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

Requirements: To convey the data content to be provided when the information is more than a simple code or period.

Cardinality: 0..1

Type: *

ExplanationOfBenefit.supportingInfo.reason

Explanation for the information

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

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

Requirements: Needed when the supporting information has both a date and amount/value and requires explanation.

Cardinality: 0..1

Type: Coding

Binding: example:missing-tooth-reason

ExplanationOfBenefit.diagnosis

Pertinent diagnosis information

Definition: Information about diagnoses relevant to the claim items.

Requirements: Required for the adjudication by provided context for the services and product listed.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.diagnosis.sequence

Diagnosis instance identifier

Definition: A number to uniquely identify diagnosis entries.

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

Requirements: Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.diagnosis.diagnosis[x]

Nature of illness or problem

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

Requirements: Provides health context for the evaluation of the products and/or services.

Cardinality: 1..1

Type: CodeableConcept, Reference(Condition)

Binding: example:icd-10

ExplanationOfBenefit.diagnosis.type

Timing or nature of the diagnosis

Definition: When the condition was observed or the relative ranking.

Comments: For example: admitting, primary, secondary, discharge.

Requirements: Often required to capture a particular diagnosis, for example: primary or discharge.

Cardinality: 0..*

Type: CodeableConcept

Binding: preferred:ex-diagnosistype

ExplanationOfBenefit.diagnosis.onAdmission

Present on admission

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

Requirements: Many systems need to understand for adjudication if the diagnosis was present a time of admission.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:ex-diagnosis-on-admission

ExplanationOfBenefit.procedure

Clinical procedures performed

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

Requirements: The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.procedure.sequence

Procedure instance identifier

Definition: A number to uniquely identify procedure entries.

Requirements: Necessary to provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.procedure.type

Category of Procedure

Definition: When the condition was observed or the relative ranking.

Requirements: Often required to capture a particular diagnosis, for example: primary or discharge.

Cardinality: 0..*

Type: CodeableConcept

Binding: preferred:ex-procedure-type

ExplanationOfBenefit.procedure.date

When the procedure was performed

Definition: Date and optionally time the procedure was performed.

Requirements: Required for auditing purposes.

Cardinality: 0..1

Type: dateTime

ExplanationOfBenefit.procedure.procedure[x]

Specific clinical procedure

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

Requirements: This identifies the actual clinical procedure.

Cardinality: 1..1

Type: CodeableConcept, Reference(Procedure)

Binding: example:icd-10-procedures

ExplanationOfBenefit.procedure.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

ExplanationOfBenefit.precedence

Precedence (primary, secondary, etc.)

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

Requirements: Needed to coordinate between multiple EOBs for the same suite of services.

Cardinality: 0..1

Type: positiveInt

ExplanationOfBenefit.insurance

Patient insurance information

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

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

Requirements: At least one insurer is required for a claim to be a claim.

Cardinality: 0..*

Type: BackboneElement

Summary: true

Mappings: v2=Coverage

ExplanationOfBenefit.insurance.focal

Coverage to be used for adjudication

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

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

Requirements: To identify which coverage in the list is being used to adjudicate this claim.

Cardinality: 1..1

Type: boolean

Summary: true

ExplanationOfBenefit.insurance.coverage

Insurance information

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

Requirements: Required to allow the adjudicator to locate the correct policy and history within their information system.

Cardinality: 1..1

Type: Reference(Coverage)

Summary: true

ExplanationOfBenefit.insurance.preAuthRef

Prior authorization reference number

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

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

Requirements: Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Cardinality: 0..*

Type: string

ExplanationOfBenefit.accident

Details of the event

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

Requirements: When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

Cardinality: 0..1

Type: BackboneElement

ExplanationOfBenefit.accident.date

When the incident occurred

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

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

Requirements: Required for audit purposes and adjudication.

Cardinality: 0..1

Type: date

ExplanationOfBenefit.accident.type

The nature of the accident

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

Requirements: Coverage may be dependant on the type of accident.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:v3-ActIncidentCode

ExplanationOfBenefit.accident.location[x]

Where the event occurred

Definition: The physical location of the accident event.

Requirements: Required for audit purposes and determination of applicable insurance liability.

Cardinality: 0..1

Type: Address, Reference(Location)

ExplanationOfBenefit.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item

Product or service provided

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

Requirements: The items to be processed for adjudication.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.item.sequence

Item instance identifier

Definition: A number to uniquely identify item entries.

Requirements: Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.item.careTeamSequence

Applicable care team members

Definition: Care team members related to this service or product.

Requirements: Need to identify the individuals and their roles in the provision of the product or service.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.diagnosisSequence

Applicable diagnoses

Definition: Diagnoses applicable for this service or product.

Requirements: Need to related the product or service to the associated diagnoses.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.procedureSequence

Applicable procedures

Definition: Procedures applicable for this service or product.

Requirements: Need to provide any listed specific procedures to support the product or service being claimed.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.informationSequence

Applicable exception and supporting information

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

Requirements: Need to reference the supporting information items that relate directly to this product or service.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.item.subject

The recipient of the products and services

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

Comments: Profilers should consider making this element required when the backbone .subject is a group.

Cardinality: 0..1

Type: Reference(Patient, Group)

ExplanationOfBenefit.item.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.item.category

Benefit classification

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

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

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ExplanationOfBenefit.item.productOrService

Billing, service, product, or drug code

Definition: When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

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

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.productOrServiceEnd

End of a range of codes

Definition: This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.request

Request or Referral for Service

Definition: Request or Referral for Goods or Service to be rendered.

Requirements: May identify the service to be provided or provider authorization for the service.

Cardinality: 0..*

Type: Reference(DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, VisionPrescription)

ExplanationOfBenefit.item.modifier

Product or service billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.item.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

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

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

ExplanationOfBenefit.item.serviced[x]

Date or dates of service or product delivery

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

Requirements: Needed to determine whether the service or product was provided during the term of the insurance coverage.

Cardinality: 0..1

Type: date, Period

Mappings: w5=FiveWs.done[x]

ExplanationOfBenefit.item.location[x]

Place of service or where product was supplied

Definition: Where the product or service was provided.

Requirements: The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Cardinality: 0..1

Type: CodeableConcept, Address, Reference(Location)

Binding: example:service-place

Mappings: w5=FiveWs.where[x]

ExplanationOfBenefit.item.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.item.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.factor

Price scaling factor

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

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.item.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

ExplanationOfBenefit.item.bodySite

Anatomical location

Definition: Physical location where the service is performed or applies.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.item.bodySite.site

Location

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

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

Requirements: Allows insurer to validate specific procedures.

Cardinality: 1..*

Type: CodeableReference

Binding: example:tooth

ExplanationOfBenefit.item.bodySite.subSite

Sub-location

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

Requirements: Allows insurer to validate specific procedures.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:surface

ExplanationOfBenefit.item.encounter

Encounters associated with the listed treatments

Definition: Healthcare encounters related to this claim.

Requirements: Used in some jurisdictions to link clinical events to claim items.

Cardinality: 0..*

Type: Reference(Encounter)

ExplanationOfBenefit.item.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.reviewOutcome

Adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

Type: BackboneElement

ExplanationOfBenefit.item.reviewOutcome.decision

Result of the adjudication

Definition: The result of the claim, predetermination, or preauthorization adjudication.

Requirements: To advise the requestor of the result of the adjudication process.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-decision

ExplanationOfBenefit.item.reviewOutcome.reason

Reason for result of the adjudication

Definition: The reasons for the result of the claim, predetermination, or preauthorization adjudication.

Requirements: To advise the requestor of the contributors to the result of the adjudication process.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-decision-reason

ExplanationOfBenefit.item.reviewOutcome.preAuthRef

Preauthorization reference

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

Comments: This value is only present on preauthorization adjudications.

Requirements: On subsequent claims, the insurer may require the provider to quote this value.

Cardinality: 0..1

Type: string

ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod

Preauthorization reference effective period

Definition: The time frame during which this authorization is effective.

Requirements: To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Cardinality: 0..1

Type: Period

ExplanationOfBenefit.item.adjudication

Adjudication details

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

Requirements: The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.item.adjudication.category

Type of adjudication information

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

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

Requirements: Needed to enable understanding of the context of the other information in the adjudication.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:adjudication

ExplanationOfBenefit.item.adjudication.reason

Explanation of adjudication outcome

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

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

Requirements: To support understanding of variance from adjudication expectations.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:adjudication-reason

ExplanationOfBenefit.item.adjudication.amount

Monetary amount

Definition: Monetary amount associated with the category.

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

Requirements: Most adjudication categories convey a monetary amount.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.adjudication.quantity

Non-monitary value

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

Comments: For example: eligible percentage or co-payment percentage.

Requirements: Some adjudication categories convey a percentage or a fixed value.

Cardinality: 0..1

Type: Quantity

ExplanationOfBenefit.item.adjudication.decisionDate

When was adjudication performed

Definition: The date and time the adjudication decision occured.

Comments: Implementation Guide authors may choose to require this element based on local regulatory requirements.

Cardinality: 0..1

Type: dateTime

ExplanationOfBenefit.item.detail

Additional items

Definition: Second-tier of goods and services.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.item.detail.sequence

Product or service provided

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

Requirements: The items to be processed for adjudication.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.item.detail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.item.detail.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.item.detail.category

Benefit classification

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

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

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ExplanationOfBenefit.item.detail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.detail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.detail.modifier

Service/Product billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.item.detail.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

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

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

ExplanationOfBenefit.item.detail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.item.detail.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.factor

Price scaling factor

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.item.detail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

ExplanationOfBenefit.item.detail.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.detail.reviewOutcome

Detail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ExplanationOfBenefit.item.detail.adjudication

Detail level adjudication details

Definition: The adjudication results.

Cardinality: 0..*

ExplanationOfBenefit.item.detail.subDetail

Additional items

Definition: Third-tier of goods and services.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.item.detail.subDetail.sequence

Product or service provided

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

Requirements: The items to be processed for adjudication.

Cardinality: 1..1

Type: positiveInt

ExplanationOfBenefit.item.detail.subDetail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.item.detail.subDetail.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.item.detail.subDetail.category

Benefit classification

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

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

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ExplanationOfBenefit.item.detail.subDetail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.item.detail.subDetail.modifier

Service/Product billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.item.detail.subDetail.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

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

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

ExplanationOfBenefit.item.detail.subDetail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.subDetail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.item.detail.subDetail.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.subDetail.factor

Price scaling factor

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.item.detail.subDetail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.subDetail.net

Total item cost

Definition: The total amount claimed for the line item.detail.subDetail. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.item.detail.subDetail.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

ExplanationOfBenefit.item.detail.subDetail.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.item.detail.subDetail.reviewOutcome

Subdetail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ExplanationOfBenefit.item.detail.subDetail.adjudication

Subdetail level adjudication details

Definition: The adjudication results.

Cardinality: 0..*

ExplanationOfBenefit.addItem

Insurer added line items

Definition: The first-tier service adjudications for payer added product or service lines.

Requirements: Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.addItem.itemSequence

Item sequence number

Definition: Claim items which this service line is intended to replace.

Requirements: Provides references to the claim items.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.detailSequence

Detail sequence number

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

Requirements: Provides references to the claim details within the claim item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.subDetailSequence

Subdetail sequence number

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

Requirements: Provides references to the claim sub-details within the claim detail.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.addItem.subject

The recipient of the products and services

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

Comments: Profilers should consider making this element required when the backbone .subject is a group.

Cardinality: 0..1

Type: Reference(Patient, Group)

ExplanationOfBenefit.addItem.informationSequence

Applicable exception and supporting information

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

Requirements: Need to reference the supporting information items that relate directly to this product or service.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.provider

Authorized providers

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

Requirements: Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Cardinality: 0..*

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.source

ExplanationOfBenefit.addItem.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.addItem.category

Benefit classification

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

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

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ExplanationOfBenefit.addItem.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.request

Request or Referral for Service

Definition: Request or Referral for Goods or Service to be rendered.

Requirements: May identify the service to be provided or provider authorization for the service.

Cardinality: 0..*

Type: Reference(DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, VisionPrescription)

ExplanationOfBenefit.addItem.modifier

Service/Product billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.addItem.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

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

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

ExplanationOfBenefit.addItem.serviced[x]

Date or dates of service or product delivery

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

Requirements: Needed to determine whether the service or product was provided during the term of the insurance coverage.

Cardinality: 0..1

Type: date, Period

Mappings: w5=FiveWs.done[x]

ExplanationOfBenefit.addItem.location[x]

Place of service or where product was supplied

Definition: Where the product or service was provided.

Requirements: The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Cardinality: 0..1

Type: CodeableConcept, Address, Reference(Location)

Binding: example:service-place

Mappings: w5=FiveWs.where[x]

ExplanationOfBenefit.addItem.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.addItem.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.factor

Price scaling factor

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.addItem.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.bodySite

Anatomical location

Definition: Physical location where the service is performed or applies.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.addItem.bodySite.site

Location

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

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

Requirements: Allows insurer to validate specific procedures.

Cardinality: 1..*

Type: CodeableReference

Binding: example:tooth

ExplanationOfBenefit.addItem.bodySite.subSite

Sub-location

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

Requirements: Allows insurer to validate specific procedures.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:surface

ExplanationOfBenefit.addItem.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.reviewOutcome

Additem level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ExplanationOfBenefit.addItem.adjudication

Added items adjudication

Definition: The adjudication results.

Cardinality: 0..*

ExplanationOfBenefit.addItem.detail

Insurer added line items

Definition: The second-tier service adjudications for payer added services.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.addItem.detail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.addItem.detail.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.addItem.detail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.detail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.detail.modifier

Service/Product billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.addItem.detail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.addItem.detail.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.factor

Price scaling factor

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.addItem.detail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.detail.reviewOutcome

Additem detail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ExplanationOfBenefit.addItem.detail.adjudication

Added items adjudication

Definition: The adjudication results.

Cardinality: 0..*

ExplanationOfBenefit.addItem.detail.subDetail

Insurer added line items

Definition: The third-tier service adjudications for payer added services.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.addItem.detail.subDetail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ExplanationOfBenefit.addItem.detail.subDetail.revenue

Revenue or cost center code

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

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ExplanationOfBenefit.addItem.detail.subDetail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ExplanationOfBenefit.addItem.detail.subDetail.modifier

Service/Product billing modifiers

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

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

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

ExplanationOfBenefit.addItem.detail.subDetail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.subDetail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

ExplanationOfBenefit.addItem.detail.subDetail.unitPrice

Fee, charge or cost per item

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

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.subDetail.factor

Price scaling factor

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

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ExplanationOfBenefit.addItem.detail.subDetail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.subDetail.net

Total item cost

Definition: The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor.

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

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.addItem.detail.subDetail.noteNumber

Applicable note numbers

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

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome

Additem subdetail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ExplanationOfBenefit.addItem.detail.subDetail.adjudication

Added items adjudication

Definition: The adjudication results.

Cardinality: 0..*

ExplanationOfBenefit.adjudication

Header-level adjudication

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

Requirements: Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Cardinality: 0..*

ExplanationOfBenefit.total

Adjudication totals

Definition: Categorized monetary totals for the adjudication.

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

Requirements: To provide the requestor with financial totals by category for the adjudication.

Cardinality: 0..*

Type: BackboneElement

Summary: true

ExplanationOfBenefit.total.category

Type of adjudication information

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

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

Requirements: Needed to convey the type of total provided.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:adjudication

Summary: true

ExplanationOfBenefit.total.amount

Financial total for the category

Definition: Monetary total amount associated with the category.

Requirements: Needed to convey the total monetary amount.

Cardinality: 1..1

Type: Money

Summary: true

ExplanationOfBenefit.payment

Payment Details

Definition: Payment details for the adjudication of the claim.

Requirements: Needed to convey references to the financial instrument that has been used if payment has been made.

Cardinality: 0..1

Type: BackboneElement

ExplanationOfBenefit.payment.type

Partial or complete payment

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

Requirements: To advise the requestor when the insurer believes all payments to have been completed.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:ex-paymenttype

ExplanationOfBenefit.payment.adjustment

Payment adjustment for non-claim issues

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

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

Requirements: To advise the requestor of adjustments applied to the payment.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.payment.adjustmentReason

Explanation for the variance

Definition: Reason for the payment adjustment.

Requirements: Needed to clarify the monetary adjustment.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:payment-adjustment-reason

ExplanationOfBenefit.payment.date

Expected date of payment

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

Requirements: To advise the payee when payment can be expected.

Cardinality: 0..1

Type: date

ExplanationOfBenefit.payment.amount

Payable amount after adjustment

Definition: Benefits payable less any payment adjustment.

Requirements: Needed to provide the actual payment amount.

Cardinality: 0..1

Type: Money

ExplanationOfBenefit.payment.identifier

Business identifier for the payment

Definition: Issuer's unique identifier for the payment instrument.

Comments: For example: EFT number or check number.

Requirements: Enable the receiver to reconcile when payment received.

Cardinality: 0..1

Type: Identifier

ExplanationOfBenefit.formCode

Printed form identifier

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

Comments: May be needed to identify specific jurisdictional forms.

Requirements: Needed to specify the specific form used for producing output for this response.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:forms

ExplanationOfBenefit.form

Printed reference or actual form

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

Comments: Needed to permit insurers to include the actual form.

Requirements: Needed to include the specific form used for producing output for this response.

Cardinality: 0..1

Type: Attachment

ExplanationOfBenefit.processNote

Note concerning adjudication

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

Requirements: Provides the insurer specific textual explanations associated with the processing.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.processNote.class

Business kind of note

Definition: A code to indicate the business purpose of the note.

Requirements: Process Notes may encompass a significant number of kinds of notes. These could be disclaimers (particularly useful for predetermination), a statement about adjudication, a conditional statement, or others.

Cardinality: 0..1

Type: CodeableConcept

Binding: example

ExplanationOfBenefit.processNote.number

Note instance identifier

Definition: A number to uniquely identify a note entry.

Requirements: Necessary to provide a mechanism to link from adjudications.

Cardinality: 0..1

Type: positiveInt

ExplanationOfBenefit.processNote.type

Note purpose

Definition: The business purpose of the note text.

Requirements: To convey the expectation for when the text is used.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:note-type

ExplanationOfBenefit.processNote.text

Note explanatory text

Definition: The explanation or description associated with the processing.

Requirements: Required to provide human readable explanation.

Cardinality: 0..1

Type: markdown

ExplanationOfBenefit.processNote.language

Language of the text

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

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

Requirements: Note text may vary from the resource defined language.

Cardinality: 0..1

Type: CodeableConcept

Binding: required:all-languages

ExplanationOfBenefit.benefitPeriod

When the benefits are applicable

Definition: The term of the benefits documented in this response.

Comments: Not applicable when use=claim.

Requirements: Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Cardinality: 0..1

Type: Period

ExplanationOfBenefit.benefitBalance

Balance by Benefit Category

Definition: Balance by Benefit Category.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.benefitBalance.category

Benefit classification

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

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

Requirements: Needed to convey the category of service or product for which eligibility is sought.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ExplanationOfBenefit.benefitBalance.excluded

Excluded from the plan

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

Requirements: Needed to identify items that are specifically excluded from the coverage.

Cardinality: 0..1

Type: boolean

ExplanationOfBenefit.benefitBalance.name

Short name for the benefit

Definition: A short name or tag for the benefit.

Comments: For example: MED01, or DENT2.

Requirements: Required to align with other plan names.

Cardinality: 0..1

Type: string

ExplanationOfBenefit.benefitBalance.description

Description of the benefit or services covered

Definition: A richer description of the benefit or services covered.

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

Requirements: Needed for human readable reference.

Cardinality: 0..1

Type: string

ExplanationOfBenefit.benefitBalance.network

In or out of network

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

Requirements: Needed as in or out of network providers are treated differently under the coverage.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:benefit-network

ExplanationOfBenefit.benefitBalance.unit

Individual or family

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

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:benefit-unit

ExplanationOfBenefit.benefitBalance.term

Annual or lifetime

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

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:benefit-term

ExplanationOfBenefit.benefitBalance.financial

Benefit Summary

Definition: Benefits Used to date.

Cardinality: 0..*

Type: BackboneElement

ExplanationOfBenefit.benefitBalance.financial.type

Benefit classification

Definition: Classification of benefit being provided.

Comments: For example: deductible, visits, benefit amount.

Requirements: Needed to convey the nature of the benefit.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:benefit-type

ExplanationOfBenefit.benefitBalance.financial.allowed[x]

Benefits allowed

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

Requirements: Needed to convey the benefits offered under the coverage.

Cardinality: 0..1

Type: unsignedInt, string, Money

ExplanationOfBenefit.benefitBalance.financial.used[x]

Benefits used

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

Requirements: Needed to convey the benefits consumed to date.

Cardinality: 0..1

Type: unsignedInt, Money

ClaimResponse.error

Processing errors

Definition: Errors encountered during the processing of the adjudication.

Comments: If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Requirements: Need to communicate processing issues to the requestor.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.error.itemSequence

Item sequence number

Definition: The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim items.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.detailSequence

Detail sequence number

Definition: The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim details within the claim item.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.subDetailSequence

Subdetail sequence number

Definition: The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim sub-details within the claim detail.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.code

Error code detailing processing issues

Definition: An error code, from a specified code system, which details why the claim could not be adjudicated.

Requirements: Required to convey processing errors.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:adjudication-error

ExplanationOfBenefit.error.expression

FHIRPath of element(s) related to issue

Definition: A simple subset of FHIRPath limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised.

Comments: The root of the FHIRPath is the resource or bundle that generated OperationOutcome. Each FHIRPath SHALL resolve to a single node.

Requirements: Allows systems to highlight or otherwise guide users to elements implicated in issues to allow them to be fixed more easily.

Cardinality: 0..*

Type: string

Summary: true