ExplanationOfBenefit

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.

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	Business Identifier for the resource Details A unique identifier assigned to this explanation of benefit.
status	✓	code	active | cancelled | draft | entered-in-error Details The status of the resource instance. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
type	✓	CodeableConcept	Category or discipline Details The category of claim, e.g. oral, pharmacy, vision, institutional, professional. 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.
subType		CodeableConcept	More granular claim type Details A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. This may contain the local bill type codes such as the US UB-04 bill type code.
use	✓	code	claim | preauthorization | predetermination Details A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
patient	✓	Reference<Patient>	The recipient of the products and services Details The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.
billablePeriod		Period	Relevant time frame for the claim Details The period for which charges are being submitted. 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.
created	✓	dateTime	Response creation date Details The date this resource was created. This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
enterer		Reference<Practitioner | PractitionerRole>	Author of the claim Details Individual who created the claim, predetermination or preauthorization.
insurer	✓	Reference<Organization>	Party responsible for reimbursement Details The party responsible for authorization, adjudication and reimbursement.
provider	✓	Reference< Practitioner | PractitionerRole | Organization >	Party responsible for the claim Details The provider which is responsible for the claim, predetermination or preauthorization. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
priority		CodeableConcept	Desired processing urgency Details The provider-required urgency of processing the request. Typical values include: stat, routine deferred. If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
fundsReserveRequested		CodeableConcept	For whom to reserve funds Details A code to indicate whether and for whom funds are to be reserved for future claims. This field is only used for preauthorizations.
fundsReserve		CodeableConcept	Funds reserved status Details A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
related		ExplanationOfBenefitRelated[]	Prior or corollary claims Details Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. For example, for the original treatment and follow-up exams.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
claim		Reference<Claim>	Reference to the related claim Details Reference to a related claim.
relationship		CodeableConcept	How the reference claim is related Details A code to convey how the claims are related. For example, prior claim or umbrella.
reference		Identifier	File or case reference Details An alternate organizational reference to the case or file to which this particular claim pertains. For example, Property/Casualty insurer claim number or Workers Compensation case number.
prescription		Reference<MedicationRequest | VisionPrescription>	Prescription authorizing services or products Details Prescription to support the dispensing of pharmacy, device or vision products.
originalPrescription		Reference<MedicationRequest>	Original prescription if superceded by fulfiller Details Original prescription which has been superseded 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 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'.
payee		ExplanationOfBenefitPayee	Recipient of benefits payable Details The party to be reimbursed for cost of the products and services according to the terms of the policy. Often 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
type		CodeableConcept	Category of recipient Details Type of Party to be reimbursed: Subscriber, provider, other.
party		Reference< Practitioner | PractitionerRole | Organization | Patient | RelatedPerson >	Recipient reference Details Reference to the individual or organization to whom any payment will be made. Not required if the payee is 'subscriber' or 'provider'.
referral		Reference<ServiceRequest>	Treatment Referral Details A reference to a referral resource. The referral resource which lists the date, practitioner, reason and other supporting information.
facility		Reference<Location>	Servicing Facility Details Facility where the services were provided.
claim		Reference<Claim>	Claim reference Details The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
claimResponse		Reference<ClaimResponse>	Claim response reference Details The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.
outcome	✓	code	queued | complete | error | partial Details The outcome of the claim, predetermination, or preauthorization processing. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
disposition		string	Disposition Message Details A human readable description of the status of the adjudication.
preAuthRef		string[]	Preauthorization reference Details Reference from the Insurer which is used in later communications which refers to this adjudication. This value is only present on preauthorization adjudications.
preAuthRefPeriod		Period[]	Preauthorization in-effect period Details The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. This value is only present on preauthorization adjudications.
careTeam		ExplanationOfBenefitCareTeam[]	Care Team members Details The members of the team who provided the products and services.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Order of care team Details A number to uniquely identify care team entries.
provider	✓	Reference< Practitioner | PractitionerRole | Organization >	Practitioner or organization Details Member of the team who provided the product or service.
responsible		boolean	Indicator of the lead practitioner Details The party who is billing and/or responsible for the claimed products or services. Responsible might not be required when there is only a single provider listed.
role		CodeableConcept	Function within the team Details The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. Role might not be required when there is only a single provider listed.
qualification		CodeableConcept	Practitioner credential or specialization Details The qualification of the practitioner which is applicable for this service.
supportingInfo		ExplanationOfBenefitSupportingInfo[]	Supporting information Details Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific valuesets which are required.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Information instance identifier Details A number to uniquely identify supporting information entries.
category	✓	CodeableConcept	Classification of the supplied information Details The general class of the information supplied: information; exception; accident, employment; onset, etc. This may contain a category for the local bill type codes.
code		CodeableConcept	Type of information Details System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. This may contain the local bill type codes such as the US UB-04 bill type code.
timing[x]		date, Period	When it occurred Details The date when or period to which this information refers.
value[x]		boolean, string, Quantity, Attachment, Reference<Resource>	Data to be provided Details Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. 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.
reason		Coding	Explanation for the information Details Provides the reason in the situation where a reason code is required in addition to the content. For example: the reason for the additional stay, or why a tooth is missing.
diagnosis		ExplanationOfBenefitDiagnosis[]	Pertinent diagnosis information Details Information about diagnoses relevant to the claim items.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Diagnosis instance identifier Details A number to uniquely identify diagnosis entries. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
diagnosis[x]	✓	CodeableConcept, Reference<Condition>	Nature of illness or problem Details The nature of illness or problem in a coded form or as a reference to an external defined Condition.
type		CodeableConcept[]	Timing or nature of the diagnosis Details When the condition was observed or the relative ranking. For example: admitting, primary, secondary, discharge.
onAdmission		CodeableConcept	Present on admission Details Indication of whether the diagnosis was present on admission to a facility.
packageCode		CodeableConcept	Package billing code Details 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. For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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.
procedure		ExplanationOfBenefitProcedure[]	Clinical procedures performed Details Procedures performed on the patient relevant to the billing items with the claim.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Procedure instance identifier Details A number to uniquely identify procedure entries.
type		CodeableConcept[]	Category of Procedure Details When the condition was observed or the relative ranking.
date		dateTime	When the procedure was performed Details Date and optionally time the procedure was performed.
procedure[x]	✓	CodeableConcept, Reference<Procedure>	Specific clinical procedure Details The code or reference to a Procedure resource which identifies the clinical intervention performed.
udi		Reference<Device>[]	Unique device identifier Details Unique Device Identifiers associated with this line item.
precedence		positiveInt	Precedence (primary, secondary, etc.) Details This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.
insurance	✓	ExplanationOfBenefitInsurance[]	Patient insurance information Details Financial instruments for reimbursement for the health care products and services specified on the claim. 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
focal	✓	boolean	Coverage to be used for adjudication Details A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. 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.
coverage	✓	Reference<Coverage>	Insurance information Details 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.
preAuthRef		string[]	Prior authorization reference number Details 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. 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.
accident		ExplanationOfBenefitAccident	Details of the event Details Details of a accident which resulted in injuries which required the products and services listed in the claim.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
date		date	When the incident occurred Details Date of an accident event related to the products and services contained in the claim. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
type		CodeableConcept	The nature of the accident Details The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
location[x]		Address, Reference<Location>	Where the event occurred Details The physical location of the accident event.
item		ExplanationOfBenefitItem[]	Product or service provided Details 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Item instance identifier Details A number to uniquely identify item entries.
careTeamSequence		positiveInt[]	Applicable care team members Details Care team members related to this service or product.
diagnosisSequence		positiveInt[]	Applicable diagnoses Details Diagnoses applicable for this service or product.
procedureSequence		positiveInt[]	Applicable procedures Details Procedures applicable for this service or product.
informationSequence		positiveInt[]	Applicable exception and supporting information Details Exceptions, special conditions and supporting information applicable for this service or product.
revenue		CodeableConcept	Revenue or cost center code Details The type of revenue or cost center providing the product and/or service.
category		CodeableConcept	Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Product or service billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
programCode		CodeableConcept[]	Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.
serviced[x]		date, Period	Date or dates of service or product delivery Details The date or dates when the service or product was supplied, performed or completed.
location[x]		CodeableConcept, Address, Reference<Location>	Place of service or where product was supplied Details Where the product or service was provided.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
udi		Reference<Device>[]	Unique device identifier Details Unique Device Identifiers associated with this line item.
bodySite		CodeableConcept	Anatomical location Details Physical service site on the patient (limb, tooth, etc.). For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
subSite		CodeableConcept[]	Anatomical sub-location Details A region or surface of the bodySite, e.g. limb region or tooth surface(s).
encounter		Reference<Encounter>[]	Encounters related to this billed item Details A billed item may include goods or services provided in multiple encounters.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		ExplanationOfBenefitItemAdjudication[]	Adjudication details Details 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
category	✓	CodeableConcept	Type of adjudication information Details 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. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
reason		CodeableConcept	Explanation of adjudication outcome Details A code supporting the understanding of the adjudication result and explaining variance from expected amount. For example, may indicate that the funds for this benefit type have been exhausted.
amount		Money	Monetary amount Details Monetary amount associated with the category. For example, amount submitted, eligible amount, co-payment, and benefit payable.
value		decimal	Non-monitary value Details A non-monetary value associated with the category. Mutually exclusive to the amount element above. For example: eligible percentage or co-payment percentage.
detail		ExplanationOfBenefitItemDetail[]	Additional items Details Second-tier of goods and services.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Product or service provided Details A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
revenue		CodeableConcept	Revenue or cost center code Details The type of revenue or cost center providing the product and/or service.
category		CodeableConcept	Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
programCode		CodeableConcept[]	Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
udi		Reference<Device>[]	Unique device identifier Details Unique Device Identifiers associated with this line item.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		[]	Detail level adjudication details Details The adjudication results.
subDetail		ExplanationOfBenefitItemDetailSubDetail[]	Additional items Details Third-tier of goods and services.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
sequence	✓	positiveInt	Product or service provided Details A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
revenue		CodeableConcept	Revenue or cost center code Details The type of revenue or cost center providing the product and/or service.
category		CodeableConcept	Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
programCode		CodeableConcept[]	Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
udi		Reference<Device>[]	Unique device identifier Details Unique Device Identifiers associated with this line item.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		[]	Subdetail level adjudication details Details The adjudication results.
addItem		ExplanationOfBenefitAddItem[]	Insurer added line items Details The first-tier service adjudications for payor added product or service lines.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
itemSequence		positiveInt[]	Item sequence number Details Claim items which this service line is intended to replace.
detailSequence		positiveInt[]	Detail sequence number Details The sequence number of the details within the claim item which this line is intended to replace.
subDetailSequence		positiveInt[]	Subdetail sequence number Details The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
provider		Reference< Practitioner | PractitionerRole | Organization >[]	Authorized providers Details The providers who are authorized for the services rendered to the patient.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
programCode		CodeableConcept[]	Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program.
serviced[x]		date, Period	Date or dates of service or product delivery Details The date or dates when the service or product was supplied, performed or completed.
location[x]		CodeableConcept, Address, Reference<Location>	Place of service or where product was supplied Details Where the product or service was provided.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
bodySite		CodeableConcept	Anatomical location Details Physical service site on the patient (limb, tooth, etc.). For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
subSite		CodeableConcept[]	Anatomical sub-location Details A region or surface of the bodySite, e.g. limb region or tooth surface(s).
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		[]	Added items adjudication Details The adjudication results.
detail		ExplanationOfBenefitAddItemDetail[]	Insurer added line items Details The second-tier service adjudications for payor added services.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		[]	Added items adjudication Details The adjudication results.
subDetail		ExplanationOfBenefitAddItemDetailSubDetail[]	Insurer added line items Details The third-tier service adjudications for payor added services.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
productOrService	✓	CodeableConcept	Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. 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'.
modifier		CodeableConcept[]	Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. 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.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	Fee, charge or cost per item Details 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.
factor		decimal	Price scaling factor Details 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. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
net		Money	Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication		[]	Added items adjudication Details The adjudication results.
adjudication		[]	Header-level adjudication Details The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
total		ExplanationOfBenefitTotal[]	Adjudication totals Details Categorized monetary totals for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
category	✓	CodeableConcept	Type of adjudication information Details 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. For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
amount	✓	Money	Financial total for the category Details Monetary total amount associated with the category.
payment		ExplanationOfBenefitPayment	Payment Details Details Payment details for the adjudication of the claim.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
type		CodeableConcept	Partial or complete payment Details Whether this represents partial or complete payment of the benefits payable.
adjustment		Money	Payment adjustment for non-claim issues Details Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. 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.
adjustmentReason		CodeableConcept	Explanation for the variance Details Reason for the payment adjustment.
date		date	Expected date of payment Details Estimated date the payment will be issued or the actual issue date of payment.
amount		Money	Payable amount after adjustment Details Benefits payable less any payment adjustment.
identifier		Identifier	Business identifier for the payment Details Issuer's unique identifier for the payment instrument. For example: EFT number or check number.
formCode		CodeableConcept	Printed form identifier Details A code for the form to be used for printing the content. May be needed to identify specific jurisdictional forms.
form		Attachment	Printed reference or actual form Details The actual form, by reference or inclusion, for printing the content or an EOB. Needed to permit insurers to include the actual form.
processNote		ExplanationOfBenefitProcessNote[]	Note concerning adjudication Details A note that describes or explains adjudication results in a human readable form.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
number		positiveInt	Note instance identifier Details A number to uniquely identify a note entry.
type		code	display | print | printoper Details The business purpose of the note text.
text		string	Note explanatory text Details The explanation or description associated with the processing.
language		CodeableConcept	Language of the text Details A code to define the language used in the text of the note. Only required if the language is different from the resource language.
benefitPeriod		Period	When the benefits are applicable Details The term of the benefits documented in this response. Not applicable when use=claim.
benefitBalance		ExplanationOfBenefitBenefitBalance[]	Balance by Benefit Category Details Balance by Benefit Category.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
category	✓	CodeableConcept	Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
excluded		boolean	Excluded from the plan Details 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.
name		string	Short name for the benefit Details A short name or tag for the benefit. For example: MED01, or DENT2.
description		string	Description of the benefit or services covered Details A richer description of the benefit or services covered. For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
network		CodeableConcept	In or out of network Details Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
unit		CodeableConcept	Individual or family Details Indicates if the benefits apply to an individual or to the family.
term		CodeableConcept	Annual or lifetime Details The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
financial		ExplanationOfBenefitBenefitBalanceFinancial[]	Benefit Summary Details Benefits Used to date.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
type	✓	CodeableConcept	Benefit classification Details Classification of benefit being provided. For example: deductible, visits, benefit amount.
allowed[x]		unsignedInt, string, Money	Benefits allowed Details The quantity of the benefit which is permitted under the coverage.
used[x]		unsignedInt, Money	Benefits used Details The quantity of the benefit which have been consumed to date.

Search Parameters

Name	Type	Description	Expression
care-team	reference	Member of the CareTeam	ExplanationOfBenefit.careTeam.provider
claim	reference	The reference to the claim	ExplanationOfBenefit.claim
coverage	reference	The plan under which the claim was adjudicated	ExplanationOfBenefit.insurance.coverage
created	date	The creation date for the EOB	ExplanationOfBenefit.created
detail-udi	reference	UDI associated with a line item detail product or service	ExplanationOfBenefit.item.detail.udi
disposition	string	The contents of the disposition message	ExplanationOfBenefit.disposition
encounter	reference	Encounters associated with a billed line item	ExplanationOfBenefit.item.encounter
enterer	reference	The party responsible for the entry of the Claim	ExplanationOfBenefit.enterer
facility	reference	Facility responsible for the goods and services	ExplanationOfBenefit.facility
identifier	token	The business identifier of the Explanation of Benefit	ExplanationOfBenefit.identifier
item-udi	reference	UDI associated with a line item product or service	ExplanationOfBenefit.item.udi
patient	reference	The reference to the patient	ExplanationOfBenefit.patient
payee	reference	The party receiving any payment for the Claim	ExplanationOfBenefit.payee.party
procedure-udi	reference	UDI associated with a procedure	ExplanationOfBenefit.procedure.udi
provider	reference	The reference to the provider	ExplanationOfBenefit.provider
status	token	Status of the instance	ExplanationOfBenefit.status
subdetail-udi	reference	UDI associated with a line item detail subdetail product or service	ExplanationOfBenefit.item.detail.subDetail.udi

Inherited Elements

Name	Required	Type	Description
id		string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
contained		Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Usage

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

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

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

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

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

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

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

Additional Information

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

• Financial Resource Status Lifecycle: how .status is used in the financial resources.
• Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
• Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
• Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
• RealTime Exchange and Obtaining EOBs: EOBs may be obtained using Polling or FHIR REST (SEARCH).
• Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.

Relationships

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

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

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

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

The eClaim domain includes a number of related resources

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