NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit TUDomainResourceExplanation of Benefit resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for the resource

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Explanation Of Benefit Status (Required)
... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Author of the claim
... insurer Σ0..1Reference(Organization)Party responsible for reimbursement
... provider Σ0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (Example)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (Example)
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (Example)
... related 0..*BackboneElementPrior or corollary claims

.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... payee 0..1BackboneElementRecipient of benefits payable
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... facility 0..1Reference(Location | Organization)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference

... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... careTeam 0..*BackboneElementCare Team members

.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: Claim Care Team Role Codes (Example)
.... specialty 0..1CodeableConceptPractitioner or provider specialization
Binding: Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information

.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Binding: Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
..... valueIdentifierIdentifier
.... reason 0..1CodingExplanation for the information
Binding: Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information

.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (Example)

.... onAdmission 0..1CodeableConceptPresent on admission
Binding: Example Diagnosis on Admission Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed

.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: Example Procedure Type Codes (Example)

.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier

... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ0..*BackboneElementPatient insurance information

.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number

... accident 0..1BackboneElementDetails of the event
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... patientPaid 0..1MoneyPaid by the patient
... item 0..*BackboneElementProduct or service provided

.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members

.... diagnosisSequence 0..*positiveIntApplicable diagnoses

.... procedureSequence 0..*positiveIntApplicable procedures

.... informationSequence 0..*positiveIntApplicable exception and supporting information

.... traceNumber 0..*IdentifierNumber for tracking

.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
.... request 0..*Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription)Request or Referral for Service

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier

.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Binding: Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Binding: Surface Codes (Example)

.... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1BackboneElementAdjudication results
..... decision 0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
..... reason 0..*CodeableConceptReason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes (Example)

..... preAuthRef 0..1stringPreauthorization reference
..... preAuthPeriod 0..1PeriodPreauthorization reference effective period
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... quantity 0..1QuantityNon-monitary value
.... detail 0..*BackboneElementAdditional items

..... sequence 1..1positiveIntProduct or service provided
..... traceNumber 0..*IdentifierNumber for tracking

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier

..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeDetail level adjudication results
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdditional items

...... sequence 1..1positiveIntProduct or service provided
...... traceNumber 0..*IdentifierNumber for tracking

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier

...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeSubdetail level adjudication results
...... adjudication 0..*see adjudicationSubdetail level adjudication details

... addItem 0..*BackboneElementInsurer added line items

.... itemSequence 0..*positiveIntItem sequence number

.... detailSequence 0..*positiveIntDetail sequence number

.... subDetailSequence 0..*positiveIntSubdetail sequence number

.... traceNumber 0..*IdentifierNumber for tracking

.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers

.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
.... request 0..*Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription)Request or Referral for Service

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Binding: Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Binding: Surface Codes (Example)

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1see reviewOutcomeAdditem level adjudication results
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line items

..... traceNumber 0..*IdentifierNumber for tracking

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeAdditem detail level adjudication results
..... adjudication 0..*see adjudicationAdded items adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... traceNumber 0..*IdentifierNumber for tracking

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeAdditem subdetail level adjudication results
...... adjudication 0..*see adjudicationAdded items adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Binding: Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1CodeableConceptNote purpose
Binding: NoteType (Extensible)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: All Languages (Required)
Additional BindingsPurpose
Common LanguagesStarter Set

... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category

.... category 1..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Binding: Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Binding: Benefit Term Codes (Example)
.... financial 0..*BackboneElementBenefit Summary

..... type 1..1CodeableConceptBenefit classification
Binding: Benefit Type Codes (Example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format