LinuxForHealth FHIR Implementation Guide
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LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions

Resource Profile: CDM Explanation of Benefit

Official URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-explanation-of-benefit Version: 8.0.0
Active as of 2022-11-10 Computable Name: CDMExplanationOfBenefit

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. The CDMExplanationOfBenefit profile extends the base FHIR ExplanationOfBenefit resource with additional details.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... meta 0..1ProcessMetaMetadata about a resource
... contained 0..0
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type 0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system 1..1uriThe namespace for the identifier value
.... value 1..1stringThe value that is unique
... type 1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... priority 0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (example)
... careTeam
.... role 0..1CodeableConceptFunction within the team
Binding: Claim Care Team Role Value Set (extensible)
... supportingInfo
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
... item
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claimResponseItemStatus 0..1CodeableConceptThe status of claim payment on claim item
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status
Binding: Payer Claim Status Codes Value Set (extensible)
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... quantity
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
.... adjudication
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Category Value Set (example)
... adjudication 0..*BackboneElementHeader-level adjudication
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
ExplanationOfBenefit.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
ExplanationOfBenefit.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (example)
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
... adjudication 0..*BackboneElementHeader-level adjudication
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.userequiredUse
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.adjudication.categoryexampleAdjudicationValueCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1idLogical id of this artifact
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... claimReceivedDate 0..1dateDate the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

... 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)Author of the claim
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..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): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... 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
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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 Value Set (extensible)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claimResponseItemStatus 0..1CodeableConceptThe status of claim payment on claim item
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status
Binding: Payer Claim Status Codes Value Set (extensible)
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
..... value Σ0..1decimalNumerical value (with implicit precision)
..... unit Σ0..1stringUnit representation
..... system ΣC0..1uriSystem that defines coded unit form
..... code Σ0..1codeCoded form of the unit
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Category Value Set (example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... adjudication 0..*BackboneElementHeader-level adjudication
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

.... amount 0..1MoneyMonetary amount
.... value 0..1decimalNon-monitary value
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... 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): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... 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: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.userequiredUse
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
ExplanationOfBenefit.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryexampleAdjudicationValueCodes
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Differential View

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... meta 0..1ProcessMetaMetadata about a resource
... contained 0..0
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type 0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system 1..1uriThe namespace for the identifier value
.... value 1..1stringThe value that is unique
... type 1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... priority 0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (example)
... careTeam
.... role 0..1CodeableConceptFunction within the team
Binding: Claim Care Team Role Value Set (extensible)
... supportingInfo
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
... item
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claimResponseItemStatus 0..1CodeableConceptThe status of claim payment on claim item
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status
Binding: Payer Claim Status Codes Value Set (extensible)
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... quantity
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
.... adjudication
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Category Value Set (example)
... adjudication 0..*BackboneElementHeader-level adjudication
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
ExplanationOfBenefit.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
ExplanationOfBenefit.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (example)
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
... adjudication 0..*BackboneElementHeader-level adjudication
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.userequiredUse
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.adjudication.categoryexampleAdjudicationValueCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1idLogical id of this artifact
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... claimReceivedDate 0..1dateDate the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

... 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)Author of the claim
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... provider Σ1..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): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... 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
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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 Value Set (extensible)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claimResponseItemStatus 0..1CodeableConceptThe status of claim payment on claim item
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status
Binding: Payer Claim Status Codes Value Set (extensible)
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
..... value Σ0..1decimalNumerical value (with implicit precision)
..... unit Σ0..1stringUnit representation
..... system ΣC0..1uriSystem that defines coded unit form
..... code Σ0..1codeCoded form of the unit
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Category Value Set (example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... adjudication 0..*BackboneElementHeader-level adjudication
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... adjudicationDate 0..1dateDate on which the payment status of the claim was adjudicated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

.... amount 0..1MoneyMonetary amount
.... value 0..1decimalNon-monitary value
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... 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): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... 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: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier.typeextensibleIdentifierTypeValueSet
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ExplanationOfBenefit.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
ExplanationOfBenefit.userequiredUse
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
ExplanationOfBenefit.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryexampleAdjudicationValueCodes
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

 

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