Current Build
Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the ExplanationOfBenefit resource.

ExplanationOfBenefit
Element IdExplanationOfBenefit
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.

Control1..1
Alternate NamesEOB
ExplanationOfBenefit.identifier
Element IdExplanationOfBenefit.identifier
Definition

The EOB Business Identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
ExplanationOfBenefit.status
Element IdExplanationOfBenefit.status
Definition

The status of the resource instance.

Control0..1
Terminology BindingExplanationOfBenefitStatus (Required)
Typecode
Is Modifiertrue (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)
Summarytrue
ExplanationOfBenefit.type
Element IdExplanationOfBenefit.type
Definition

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

Control0..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Comments

Affects which fields and value sets are used.

ExplanationOfBenefit.subType
Element IdExplanationOfBenefit.subType
Definition

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type.

Control0..*
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Comments

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

ExplanationOfBenefit.use
Element IdExplanationOfBenefit.use
Definition

A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.

Control0..1
Terminology BindingUse (Required)
Typecode
Summarytrue
ExplanationOfBenefit.patient
Element IdExplanationOfBenefit.patient
Definition

Patient Resource.

Control0..1
TypeReference(Patient)
ExplanationOfBenefit.billablePeriod
Element IdExplanationOfBenefit.billablePeriod
Definition

The billable period for which charges are being submitted.

Control0..1
TypePeriod
ExplanationOfBenefit.created
Element IdExplanationOfBenefit.created
Definition

The date when this resource was created.

Control0..1
TypedateTime
ExplanationOfBenefit.enterer
Element IdExplanationOfBenefit.enterer
Definition

The person who created the explanation of benefit.

Control0..1
TypeReference(Practitioner | PractitionerRole)
ExplanationOfBenefit.insurer
Element IdExplanationOfBenefit.insurer
Definition

The insurer which is responsible for the explanation of benefit.

Control0..1
TypeReference(Organization)
ExplanationOfBenefit.provider
Element IdExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization)
ExplanationOfBenefit.referral
Element IdExplanationOfBenefit.referral
Definition

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

Control0..1
TypeReference(ServiceRequest)
ExplanationOfBenefit.facility
Element IdExplanationOfBenefit.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(Location)
ExplanationOfBenefit.claim
Element IdExplanationOfBenefit.claim
Definition

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

Control0..1
TypeReference(Claim)
ExplanationOfBenefit.claimResponse
Element IdExplanationOfBenefit.claimResponse
Definition

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.

Control0..1
TypeReference(ClaimResponse)
ExplanationOfBenefit.outcome
Element IdExplanationOfBenefit.outcome
Definition

Processing outcome errror, partial or complete processing.

Control0..1
Terminology BindingClaim Processing Codes (Required)
Typecode
ExplanationOfBenefit.disposition
Element IdExplanationOfBenefit.disposition
Definition

A description of the status of the adjudication.

Control0..1
Typestring
Comments

Do we need a disposition code?

ExplanationOfBenefit.related
Element IdExplanationOfBenefit.related
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..*
ExplanationOfBenefit.related.claim
Element IdExplanationOfBenefit.related.claim
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..1
TypeReference(Claim)
Comments

Do we need a relationship code?

ExplanationOfBenefit.related.relationship
Element IdExplanationOfBenefit.related.relationship
Definition

For example, prior or umbrella.

Control0..1
Terminology BindingExample Related Claim Relationship Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.related.reference
Element IdExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains - e.g. Property/Casualy insurer claim # or Workers Compensation case # .

Control0..1
TypeIdentifier
ExplanationOfBenefit.prescription
Element IdExplanationOfBenefit.prescription
Definition

Prescription to support the dispensing of Pharmacy or Vision products.

Control0..1
TypeReference(MedicationRequest | VisionPrescription)
Requirements

For type=Pharmacy and Vision only.

ExplanationOfBenefit.originalPrescription
Element IdExplanationOfBenefit.originalPrescription
Definition

Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Control0..1
TypeReference(MedicationRequest)
ExplanationOfBenefit.payee
Element IdExplanationOfBenefit.payee
Definition

The party to be reimbursed for the services.

Control0..1
ExplanationOfBenefit.payee.type
Element IdExplanationOfBenefit.payee.type
Definition

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

Control0..1
Terminology BindingClaim Payee Type Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.payee.resource
Element IdExplanationOfBenefit.payee.resource
Definition

organization | patient | practitioner | relatedperson.

Control0..1
Terminology BindingPayeeResourceType (Extensible)
TypeCoding
ExplanationOfBenefit.payee.party
Element IdExplanationOfBenefit.payee.party
Definition

Party to be reimbursed: Subscriber, provider, other.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
ExplanationOfBenefit.information
Element IdExplanationOfBenefit.information
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Control0..*
Requirements

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

ExplanationOfBenefit.information.sequence
Element IdExplanationOfBenefit.information.sequence
Definition

Sequence of the information element which serves to provide a link.

Control1..1
TypepositiveInt
Requirements

To provide a reference link.

ExplanationOfBenefit.information.category
Element IdExplanationOfBenefit.information.category
Definition

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

Control1..1
Terminology BindingClaim Information Category Codes (Example)
TypeCodeableConcept
Comments

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

ExplanationOfBenefit.information.code
Element IdExplanationOfBenefit.information.code
Definition

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

Control0..1
Terminology BindingException Codes (Example)
TypeCodeableConcept
Comments

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

ExplanationOfBenefit.information.timing[x]
Element IdExplanationOfBenefit.information.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.information.value[x]
Element IdExplanationOfBenefit.information.value[x]
Definition

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

Control0..1
Typeboolean|string|Quantity|Attachment|Reference(Any)
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.information.reason
Element IdExplanationOfBenefit.information.reason
Definition

For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.

Control0..1
Terminology BindingMissing Tooth Reason Codes (Example)
TypeCoding
ExplanationOfBenefit.careTeam
Element IdExplanationOfBenefit.careTeam
Definition

The members of the team who provided the overall service as well as their role and whether responsible and qualifications.

Control0..*
Requirements

Role and Responsible might not be required when there is only a single provider listed.

ExplanationOfBenefit.careTeam.sequence
Element IdExplanationOfBenefit.careTeam.sequence
Definition

Sequence of careteam which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the careteam members.

ExplanationOfBenefit.careTeam.provider
Element IdExplanationOfBenefit.careTeam.provider
Definition

The members of the team who provided the overall service.

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization)
ExplanationOfBenefit.careTeam.responsible
Element IdExplanationOfBenefit.careTeam.responsible
Definition

The practitioner who is billing and responsible for the claimed services rendered to the patient.

Control0..1
Typeboolean
ExplanationOfBenefit.careTeam.role
Element IdExplanationOfBenefit.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.

Control0..1
Terminology BindingClaim Care Team Role Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.careTeam.qualification
Element IdExplanationOfBenefit.careTeam.qualification
Definition

The qualification which is applicable for this service.

Control0..1
Terminology BindingExample Provider Qualification Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.diagnosis
Element IdExplanationOfBenefit.diagnosis
Definition

Ordered list of patient diagnosis for which care is sought.

Control0..*
ExplanationOfBenefit.diagnosis.sequence
Element IdExplanationOfBenefit.diagnosis.sequence
Definition

Sequence of diagnosis which serves to provide a link.

Control1..1
TypepositiveInt
Requirements

Required to allow line items to reference the diagnoses.

ExplanationOfBenefit.diagnosis.diagnosis[x]
Element IdExplanationOfBenefit.diagnosis.diagnosis[x]
Definition

The diagnosis.

Control1..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to adjudicate services rendered to condition presented.

ExplanationOfBenefit.diagnosis.type
Element IdExplanationOfBenefit.diagnosis.type
Definition

The type of the Diagnosis, for example: admitting, primary, secondary, discharge.

Control0..*
Terminology BindingExample Diagnosis Type Codes (Example)
TypeCodeableConcept
Requirements

Required to adjudicate services rendered to the mandated diagnosis grouping system.

Comments

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

ExplanationOfBenefit.diagnosis.onAdmission
Element IdExplanationOfBenefit.diagnosis.onAdmission
Definition

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

Control0..1
Terminology BindingExample Diagnosis on Admission Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.diagnosis.packageCode
Element IdExplanationOfBenefit.diagnosis.packageCode
Definition

The package billing code, for example DRG, based on the assigned grouping code system.

Control0..1
Terminology BindingExample Diagnosis Related Group Codes (Example)
TypeCodeableConcept
Requirements

Required to adjudicate services rendered to the mandated grouping system.

ExplanationOfBenefit.procedure
Element IdExplanationOfBenefit.procedure
Definition

Ordered list of patient procedures performed to support the adjudication.

Control0..*
ExplanationOfBenefit.procedure.sequence
Element IdExplanationOfBenefit.procedure.sequence
Definition

Sequence of procedures which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the procudures.

ExplanationOfBenefit.procedure.date
Element IdExplanationOfBenefit.procedure.date
Definition

Date and optionally time the procedure was performed .

Control0..1
TypedateTime
Requirements

Required to adjudicate services rendered.

Comments

SB DateTime??

ExplanationOfBenefit.procedure.procedure[x]
Element IdExplanationOfBenefit.procedure.procedure[x]
Definition

The procedure code.

Control1..1
Terminology BindingICD-10 Procedure Codes (Example)
TypeCodeableConcept|Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to adjudicate services rendered.

ExplanationOfBenefit.precedence
Element IdExplanationOfBenefit.precedence
Definition

Precedence (primary, secondary, etc.).

Control0..1
TypepositiveInt
Requirements

Health care programs and insurers are significant payors of health service costs.

ExplanationOfBenefit.insurance
Element IdExplanationOfBenefit.insurance
Definition

Financial instrument by which payment information for health care.

Control0..1
Requirements

Health care programs and insurers are significant payors of health service costs.

ExplanationOfBenefit.insurance.coverage
Element IdExplanationOfBenefit.insurance.coverage
Definition

Reference to the program or plan identification, underwriter or payor.

Control0..1
TypeReference(Coverage)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

ExplanationOfBenefit.insurance.preAuthRef
Element IdExplanationOfBenefit.insurance.preAuthRef
Definition

A list of references from the Insurer to which these services pertain.

Control0..*
Typestring
Requirements

To provide any pre=determination or prior authorization reference.

ExplanationOfBenefit.accident
Element IdExplanationOfBenefit.accident
Definition

An accident which resulted in the need for healthcare services.

Control0..1
ExplanationOfBenefit.accident.date
Element IdExplanationOfBenefit.accident.date
Definition

Date of an accident which these services are addressing.

Control0..1
Typedate
Requirements

Coverage may be dependant on accidents.

ExplanationOfBenefit.accident.type
Element IdExplanationOfBenefit.accident.type
Definition

Type of accident: work, auto, etc.

Control0..1
Terminology BindingActIncidentCode (Extensible)
TypeCodeableConcept
Requirements

Coverage may be dependant on the type of accident.

ExplanationOfBenefit.accident.location[x]
Element IdExplanationOfBenefit.accident.location[x]
Definition

Where the accident occurred.

Control0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.item
Element IdExplanationOfBenefit.item
Definition

First-tier of goods and services.

Control0..*
ExplanationOfBenefit.item.sequence
Element IdExplanationOfBenefit.item.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
ExplanationOfBenefit.item.careTeamSequence
Element IdExplanationOfBenefit.item.careTeamSequence
Definition

Careteam applicable for this service or product line.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.diagnosisSequence
Element IdExplanationOfBenefit.item.diagnosisSequence
Definition

Diagnosis applicable for this service or product line.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.procedureSequence
Element IdExplanationOfBenefit.item.procedureSequence
Definition

Procedures applicable for this service or product line.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.informationSequence
Element IdExplanationOfBenefit.item.informationSequence
Definition

Exceptions, special conditions and supporting information pplicable for this service or product line.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.revenue
Element IdExplanationOfBenefit.item.revenue
Definition

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

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.category
Element IdExplanationOfBenefit.item.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.billcode
Element IdExplanationOfBenefit.item.billcode
Definition

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,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.modifier
Element IdExplanationOfBenefit.item.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.item.programCode
Element IdExplanationOfBenefit.item.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.serviced[x]
Element IdExplanationOfBenefit.item.serviced[x]
Definition

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

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.item.location[x]
Element IdExplanationOfBenefit.item.location[x]
Definition

Where the service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.item.quantity
Element IdExplanationOfBenefit.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.item.unitPrice
Element IdExplanationOfBenefit.item.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ExplanationOfBenefit.item.factor
Element IdExplanationOfBenefit.item.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.net
Element IdExplanationOfBenefit.item.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.udi
Element IdExplanationOfBenefit.item.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

ExplanationOfBenefit.item.bodySite
Element IdExplanationOfBenefit.item.bodySite
Definition

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

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.subSite
Element IdExplanationOfBenefit.item.subSite
Definition

A region or surface of the site, e.g. limb region or tooth surface(s).

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.encounter
Element IdExplanationOfBenefit.item.encounter
Definition

A billed item may include goods or services provided in multiple encounters.

Control0..*
TypeReference(Encounter)
ExplanationOfBenefit.item.noteNumber
Element IdExplanationOfBenefit.item.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.adjudication
Element IdExplanationOfBenefit.item.adjudication
Definition

The adjudication results.

Control0..*
ExplanationOfBenefit.item.adjudication.category
Element IdExplanationOfBenefit.item.adjudication.category
Definition

Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.adjudication.reason
Element IdExplanationOfBenefit.item.adjudication.reason
Definition

Adjudication reason such as limit reached.

Control0..1
Terminology BindingAdjudication Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.adjudication.amount
Element IdExplanationOfBenefit.item.adjudication.amount
Definition

Monitory amount associated with the code.

Control0..1
TypeMoney
ExplanationOfBenefit.item.adjudication.value
Element IdExplanationOfBenefit.item.adjudication.value
Definition

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Control0..1
Typedecimal
ExplanationOfBenefit.item.detail
Element IdExplanationOfBenefit.item.detail
Definition

Second-tier of goods and services.

Control0..*
ExplanationOfBenefit.item.detail.sequence
Element IdExplanationOfBenefit.item.detail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
ExplanationOfBenefit.item.detail.revenue
Element IdExplanationOfBenefit.item.detail.revenue
Definition

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

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.category
Element IdExplanationOfBenefit.item.detail.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.billcode
Element IdExplanationOfBenefit.item.detail.billcode
Definition

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,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.modifier
Element IdExplanationOfBenefit.item.detail.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.item.detail.programCode
Element IdExplanationOfBenefit.item.detail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.quantity
Element IdExplanationOfBenefit.item.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.item.detail.unitPrice
Element IdExplanationOfBenefit.item.detail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.factor
Element IdExplanationOfBenefit.item.detail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.net
Element IdExplanationOfBenefit.item.detail.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.udi
Element IdExplanationOfBenefit.item.detail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

ExplanationOfBenefit.item.detail.noteNumber
Element IdExplanationOfBenefit.item.detail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.detail.adjudication
Element IdExplanationOfBenefit.item.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.item.detail.subDetail
Element IdExplanationOfBenefit.item.detail.subDetail
Definition

Third-tier of goods and services.

Control0..*
ExplanationOfBenefit.item.detail.subDetail.sequence
Element IdExplanationOfBenefit.item.detail.subDetail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
ExplanationOfBenefit.item.detail.subDetail.revenue
Element IdExplanationOfBenefit.item.detail.subDetail.revenue
Definition

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

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.subDetail.category
Element IdExplanationOfBenefit.item.detail.subDetail.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.subDetail.billcode
Element IdExplanationOfBenefit.item.detail.subDetail.billcode
Definition

A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.subDetail.modifier
Element IdExplanationOfBenefit.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.item.detail.subDetail.programCode
Element IdExplanationOfBenefit.item.detail.subDetail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.item.detail.subDetail.quantity
Element IdExplanationOfBenefit.item.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.item.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.item.detail.subDetail.unitPrice
Definition

The fee for an addittional service or product or charge.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.subDetail.factor
Element IdExplanationOfBenefit.item.detail.subDetail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.subDetail.net
Element IdExplanationOfBenefit.item.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.item.detail.subDetail.udi
Element IdExplanationOfBenefit.item.detail.subDetail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

ExplanationOfBenefit.item.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.item.detail.subDetail.adjudication
Element IdExplanationOfBenefit.item.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem
Element IdExplanationOfBenefit.addItem
Definition

The first-tier service adjudications for payor added services.

Control0..*
ExplanationOfBenefit.addItem.itemSequence
Element IdExplanationOfBenefit.addItem.itemSequence
Definition

List of input service items which this service line is intended to replace.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.detailSequence
Element IdExplanationOfBenefit.addItem.detailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.subDetailSequence
Element IdExplanationOfBenefit.addItem.subDetailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.provider
Element IdExplanationOfBenefit.addItem.provider
Definition

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

Control0..*
TypeReference(Practitioner | PractitionerRole | Organization)
ExplanationOfBenefit.addItem.billcode
Element IdExplanationOfBenefit.addItem.billcode
Definition

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,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.modifier
Element IdExplanationOfBenefit.addItem.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.addItem.programCode
Element IdExplanationOfBenefit.addItem.programCode
Definition

For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.serviced[x]
Element IdExplanationOfBenefit.addItem.serviced[x]
Definition

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

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.addItem.location[x]
Element IdExplanationOfBenefit.addItem.location[x]
Definition

Where the service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.addItem.quantity
Element IdExplanationOfBenefit.addItem.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.addItem.unitPrice
Element IdExplanationOfBenefit.addItem.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ExplanationOfBenefit.addItem.factor
Element IdExplanationOfBenefit.addItem.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.net
Element IdExplanationOfBenefit.addItem.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.bodySite
Element IdExplanationOfBenefit.addItem.bodySite
Definition

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

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.subSite
Element IdExplanationOfBenefit.addItem.subSite
Definition

A region or surface of the site, e.g. limb region or tooth surface(s).

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.noteNumber
Element IdExplanationOfBenefit.addItem.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.adjudication
Element IdExplanationOfBenefit.addItem.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem.detail
Element IdExplanationOfBenefit.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Control0..*
ExplanationOfBenefit.addItem.detail.billcode
Element IdExplanationOfBenefit.addItem.detail.billcode
Definition

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,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.detail.modifier
Element IdExplanationOfBenefit.addItem.detail.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.addItem.detail.quantity
Element IdExplanationOfBenefit.addItem.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.addItem.detail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ExplanationOfBenefit.addItem.detail.factor
Element IdExplanationOfBenefit.addItem.detail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.detail.net
Element IdExplanationOfBenefit.addItem.detail.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.detail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.detail.adjudication
Element IdExplanationOfBenefit.addItem.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem.detail.subDetail
Element IdExplanationOfBenefit.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Control0..*
ExplanationOfBenefit.addItem.detail.subDetail.billcode
Element IdExplanationOfBenefit.addItem.detail.subDetail.billcode
Definition

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,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.addItem.detail.subDetail.modifier
Element IdExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

ExplanationOfBenefit.addItem.detail.subDetail.quantity
Element IdExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ExplanationOfBenefit.addItem.detail.subDetail.factor
Element IdExplanationOfBenefit.addItem.detail.subDetail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.detail.subDetail.net
Element IdExplanationOfBenefit.addItem.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Element IdExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.total
Element IdExplanationOfBenefit.total
Definition

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

Control0..*
ExplanationOfBenefit.total.category
Element IdExplanationOfBenefit.total.category
Definition

Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.total.amount
Element IdExplanationOfBenefit.total.amount
Definition

Monitory amount associated with the code.

Control1..1
TypeMoney
ExplanationOfBenefit.payment
Element IdExplanationOfBenefit.payment
Definition

Payment details for the claim if the claim has been paid.

Control0..1
ExplanationOfBenefit.payment.type
Element IdExplanationOfBenefit.payment.type
Definition

Whether this represents partial or complete payment of the claim.

Control0..1
Terminology BindingExample Payment Type Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.payment.adjustment
Element IdExplanationOfBenefit.payment.adjustment
Definition

Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Control0..1
TypeMoney
ExplanationOfBenefit.payment.adjustmentReason
Element IdExplanationOfBenefit.payment.adjustmentReason
Definition

Reason for the payment adjustment.

Control0..1
Terminology BindingPayment Adjustment Reason Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.payment.date
Element IdExplanationOfBenefit.payment.date
Definition

Estimated payment date.

Control0..1
Typedate
ExplanationOfBenefit.payment.amount
Element IdExplanationOfBenefit.payment.amount
Definition

Payable less any payment adjustment.

Control0..1
TypeMoney
ExplanationOfBenefit.payment.identifier
Element IdExplanationOfBenefit.payment.identifier
Definition

Payment identifer.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
ExplanationOfBenefit.form
Element IdExplanationOfBenefit.form
Definition

The form to be used for printing the content.

Control0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.processNote
Element IdExplanationOfBenefit.processNote
Definition

Note text.

Control0..*
ExplanationOfBenefit.processNote.number
Element IdExplanationOfBenefit.processNote.number
Definition

An integer associated with each note which may be referred to from each service line item.

Control0..1
TypepositiveInt
ExplanationOfBenefit.processNote.type
Element IdExplanationOfBenefit.processNote.type
Definition

The note purpose: Print/Display.

Control0..1
Terminology BindingNoteType (Required)
Typecode
ExplanationOfBenefit.processNote.text
Element IdExplanationOfBenefit.processNote.text
Definition

The note text.

Control0..1
Typestring
ExplanationOfBenefit.processNote.language
Element IdExplanationOfBenefit.processNote.language
Definition

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

Control0..1
Terminology BindingCommon Languages (Extensible but limited to All Languages)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance
Element IdExplanationOfBenefit.benefitBalance
Definition

Balance by Benefit Category.

Control0..*
ExplanationOfBenefit.benefitBalance.category
Element IdExplanationOfBenefit.benefitBalance.category
Definition

Dental, Vision, Medical, Pharmacy, Rehab etc.

Control1..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance.excluded
Element IdExplanationOfBenefit.benefitBalance.excluded
Definition

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

Control0..1
Typeboolean
ExplanationOfBenefit.benefitBalance.name
Element IdExplanationOfBenefit.benefitBalance.name
Definition

A short name or tag for the benefit, for example MED01, or DENT2.

Control0..1
Typestring
ExplanationOfBenefit.benefitBalance.description
Element IdExplanationOfBenefit.benefitBalance.description
Definition

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.

Control0..1
Typestring
ExplanationOfBenefit.benefitBalance.network
Element IdExplanationOfBenefit.benefitBalance.network
Definition

Network designation.

Control0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance.unit
Element IdExplanationOfBenefit.benefitBalance.unit
Definition

Unit designation: individual or family.

Control0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance.term
Element IdExplanationOfBenefit.benefitBalance.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.

Control0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance.financial
Element IdExplanationOfBenefit.benefitBalance.financial
Definition

Benefits Used to date.

Control0..*
ExplanationOfBenefit.benefitBalance.financial.type
Element IdExplanationOfBenefit.benefitBalance.financial.type
Definition

Deductable, visits, benefit amount.

Control1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Element IdExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition

Benefits allowed.

Control0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.benefitBalance.financial.used[x]
Element IdExplanationOfBenefit.benefitBalance.financial.used[x]
Definition

Benefits used.

Control0..1
TypeunsignedInt|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]