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. If the element is present, it must have either a @value, an @id, or extensions

type ExplanationOfBenefit implements Resource {
  identifier: [Identifier]
  status: String
  type: CodeableConcept
  subType: CodeableConcept
  use: String
  patient: Reference
  billablePeriod: Period
  created: Date
  enterer: Reference
  insurer: Reference
  provider: Reference
  priority: CodeableConcept
  fundsReserveRequested: CodeableConcept
  fundsReserve: CodeableConcept
  related: [ExplanationOfBenefitRelated]
  prescription: Reference
  originalPrescription: Reference
  payee: ExplanationOfBenefitPayee
  referral: Reference
  facility: Reference
  claim: Reference
  claimResponse: Reference
  outcome: String
  disposition: String
  preAuthRef: [String]
  preAuthRefPeriod: [Period]
  careTeam: [ExplanationOfBenefitCareTeam]
  supportingInfo: [ExplanationOfBenefitSupportingInfo]
  diagnosis: [ExplanationOfBenefitDiagnosis]
  procedure: [ExplanationOfBenefitProcedure]
  precedence: Int
  insurance: [ExplanationOfBenefitInsurance]
  accident: ExplanationOfBenefitAccident
  item: [ExplanationOfBenefitItem]
  addItem: [ExplanationOfBenefitAddItem]
  adjudication: [ExplanationOfBenefitAdjudication]
  total: [ExplanationOfBenefitTotal]
  payment: ExplanationOfBenefitPayment
  formCode: CodeableConcept
  form: Attachment
  processNote: [ExplanationOfBenefitProcessNote]
  benefitPeriod: Period
  benefitBalance: [ExplanationOfBenefitBenefitBalance]
  text: Narrative
  contained: [Resource]
  extension: [Extension]
  modifierExtension: [Extension]
  id: String
  meta: Meta
  implicitRules: Uri
  language: String
}

Fields

ExplanationOfBenefit.identifier ● [Identifier] list object

A unique identifier assigned to this explanation of benefit.

ExplanationOfBenefit.status ● String scalar

The status of the resource instance.

ExplanationOfBenefit.type ● CodeableConcept object

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

ExplanationOfBenefit.subType ● CodeableConcept object

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

ExplanationOfBenefit.use ● String scalar

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.

ExplanationOfBenefit.patient ● Reference object

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.

ExplanationOfBenefit.billablePeriod ● Period object

The period for which charges are being submitted.

ExplanationOfBenefit.created ● Date scalar

The date this resource was created.

ExplanationOfBenefit.enterer ● Reference object

Individual who created the claim, predetermination or preauthorization.

ExplanationOfBenefit.insurer ● Reference object

The party responsible for authorization, adjudication and reimbursement.

ExplanationOfBenefit.provider ● Reference object

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

ExplanationOfBenefit.priority ● CodeableConcept object

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

ExplanationOfBenefit.fundsReserveRequested ● CodeableConcept object

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

ExplanationOfBenefit.fundsReserve ● CodeableConcept object

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

ExplanationOfBenefit.related ● [ExplanationOfBenefitRelated] list object

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

ExplanationOfBenefit.prescription ● Reference object

Prescription to support the dispensing of pharmacy, device or vision products.

ExplanationOfBenefit.originalPrescription ● Reference object

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

ExplanationOfBenefit.payee ● ExplanationOfBenefitPayee object

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

ExplanationOfBenefit.referral ● Reference object

A reference to a referral resource.

ExplanationOfBenefit.facility ● Reference object

Facility where the services were provided.

ExplanationOfBenefit.claim ● Reference object

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

ExplanationOfBenefit.claimResponse ● Reference object

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

ExplanationOfBenefit.outcome ● String scalar

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

ExplanationOfBenefit.disposition ● String scalar

A human readable description of the status of the adjudication.

ExplanationOfBenefit.preAuthRef ● [String] list scalar

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

ExplanationOfBenefit.preAuthRefPeriod ● [Period] list object

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

ExplanationOfBenefit.careTeam ● [ExplanationOfBenefitCareTeam] list object

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

ExplanationOfBenefit.supportingInfo ● [ExplanationOfBenefitSupportingInfo] list object

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

ExplanationOfBenefit.diagnosis ● [ExplanationOfBenefitDiagnosis] list object

Information about diagnoses relevant to the claim items.

ExplanationOfBenefit.procedure ● [ExplanationOfBenefitProcedure] list object

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

ExplanationOfBenefit.precedence ● Int scalar

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

ExplanationOfBenefit.insurance ● [ExplanationOfBenefitInsurance] list object

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

ExplanationOfBenefit.accident ● ExplanationOfBenefitAccident object

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

ExplanationOfBenefit.item ● [ExplanationOfBenefitItem] list object

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.

ExplanationOfBenefit.addItem ● [ExplanationOfBenefitAddItem] list object

The first-tier service adjudications for payor added product or service lines.

ExplanationOfBenefit.adjudication ● [ExplanationOfBenefitAdjudication] list object

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

ExplanationOfBenefit.total ● [ExplanationOfBenefitTotal] list object

Categorized monetary totals for the adjudication.

ExplanationOfBenefit.payment ● ExplanationOfBenefitPayment object

Payment details for the adjudication of the claim.

ExplanationOfBenefit.formCode ● CodeableConcept object

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

ExplanationOfBenefit.form ● Attachment object

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

ExplanationOfBenefit.processNote ● [ExplanationOfBenefitProcessNote] list object

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

ExplanationOfBenefit.benefitPeriod ● Period object

The term of the benefits documented in this response.

ExplanationOfBenefit.benefitBalance ● [ExplanationOfBenefitBenefitBalance] list object

Balance by Benefit Category.

ExplanationOfBenefit.text ● Narrative object

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.

ExplanationOfBenefit.contained ● [Resource] list interface

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.

ExplanationOfBenefit.extension ● [Extension] list object

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.

ExplanationOfBenefit.modifierExtension ● [Extension] list object

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).

ExplanationOfBenefit.id ● String scalar

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ExplanationOfBenefit.meta ● Meta object

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.

ExplanationOfBenefit.implicitRules ● Uri scalar

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.

ExplanationOfBenefit.language ● String scalar

The base language in which the resource is written.

Interfaces

Resource interface

This is the base resource type for everything.

Returned By

ExplanationOfBenefit query ● ExplanationOfBenefitCreate mutation ● ExplanationOfBenefitList query ● ExplanationOfBenefitUpdate mutation