NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit DomainResourceExplanation of Benefit resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
ExplanationOfBenefitStatus (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Insurer responsible for the EOB
... provider 0..1Reference(Practitioner)Responsible provider for the claim
... organization 0..1Reference(Organization)Responsible organization for the claim
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Claim Payee Type Codes (Example)
.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
PayeeResourceType (Required)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodingReason associated with the information
Missing Tooth Reason Codes (Example)
... careTeam 0..*BackboneElementCare Team members
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... diagnosis 0..*BackboneElementList of Diagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..1BackboneElementInsurance or medical plan
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElementDetails of an accident
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
ActInvoiceGroupCode (Required)
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodeableConceptType of product or service
ActInvoiceGroupCode (Required)
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationLanguage if different from the resource
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment (if paid)
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... processNote 0..*BackboneElementProcessing notes
.... number 0..1positiveIntSequence number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage if different from the resource
Common Languages (Extensible but limited to All Languages)
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptType of services covered
Benefit Category Codes (Example)
.... subCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary
..... type 1..1CodeableConceptDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format