The ExplanationOfBenefit resource implements the FHIR R4 ExplanationOfBenefit specification

Fields

Name Type Cardinality Required Description  
identifier Identifier 0..*   Business Identifier for the resource  
status code 1..1 * active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus ( Required )  
type CodeableConcept 1..1 * Category or discipline Claim Type Codes ( Extensible )  
subType CodeableConcept 0..1   More granular claim type Example Claim SubType Codes ( Example )  
use code 1..1 * claim | preauthorization | predetermination Use ( Required )  
patient Reference(Patient) 1..1 * The recipient of the products and services  
billablePeriod Period 0..1   Relevant time frame for the claim  
created dateTime 1..1 * Response creation date  
enterer Reference(Practitioner | PractitionerRole) 0..1   Author of the claim  
insurer Reference(Organization) 1..1 * Party responsible for reimbursement  
provider Reference(Practitioner | PractitionerRole | Organization) 1..1 * Party responsible for the claim  
priority CodeableConcept 0..1   Desired processing urgency ProcessPriority ( Example )  
fundsReserveRequested CodeableConcept 0..1   For whom to reserve funds FundsReserve ( Example )  
fundsReserve CodeableConcept 0..1   Funds reserved status FundsReserve ( Example )  
related BackboneElement 0..*   Prior or corollary claims  
claim Reference(Claim) 0..1   Reference to the related claim  
relationship CodeableConcept 0..1   How the reference claim is related Example Related Claim Relationship Codes ( Example )  
reference Identifier 0..1   File or case reference  
prescription Reference(MedicationRequest | VisionPrescription) 0..1   Prescription authorizing services or products  
originalPrescription Reference(MedicationRequest) 0..1   Original prescription if superceded by fulfiller  
payee BackboneElement 0..1   Recipient of benefits payable  
type CodeableConcept 0..1   Category of recipient PayeeType ( Example )  
party Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) 0..1   Recipient reference  
referral Reference(ServiceRequest) 0..1   Treatment Referral  
facility Reference(Location) 0..1   Servicing Facility  
claim Reference(Claim) 0..1   Claim reference  
claimResponse Reference(ClaimResponse) 0..1   Claim response reference  
outcome code 1..1 * queued | complete | error | partial Claim Processing Codes ( Required )  
disposition string 0..1   Disposition Message  
preAuthRef string 0..*   Preauthorization reference  
preAuthRefPeriod Period 0..*   Preauthorization in-effect period  
careTeam BackboneElement 0..*   Care Team members  
sequence positiveInt 1..1 * Order of care team  
provider Reference(Practitioner | PractitionerRole | Organization) 1..1 * Practitioner or organization  
responsible boolean 0..1   Indicator of the lead practitioner  
role CodeableConcept 0..1   Function within the team Claim Care Team Role Codes ( Example )  
qualification CodeableConcept 0..1   Practitioner credential or specialization Example Provider Qualification Codes ( Example )  
supportingInfo BackboneElement 0..*   Supporting information  
sequence positiveInt 1..1 * Information instance identifier  
category CodeableConcept 1..1 * Classification of the supplied information Claim Information Category Codes ( Example )  
code CodeableConcept 0..1   Type of information Exception Codes ( Example )  
timing[x]   0..1   When it occurred  
timingDate date        
timingPeriod Period        
value[x]   0..1   Data to be provided  
valueBoolean boolean        
valueString string        
valueQuantity Quantity        
valueAttachment Attachment        
valueReference Reference(Any)        
reason Coding 0..1   Explanation for the information Missing Tooth Reason Codes ( Example )  
diagnosis BackboneElement 0..*   Pertinent diagnosis information  
sequence positiveInt 1..1 * Diagnosis instance identifier  
diagnosis[x]   1..1 * Nature of illness or problem ICD-10 Codes ( Example )  
diagnosisCodeableConcept CodeableConcept        
diagnosisReference Reference(Condition)        
type CodeableConcept 0..*   Timing or nature of the diagnosis Example Diagnosis Type Codes ( Example )  
onAdmission CodeableConcept 0..1   Present on admission Example Diagnosis on Admission Codes ( Example )  
packageCode CodeableConcept 0..1   Package billing code Example Diagnosis Related Group Codes ( Example )  
procedure BackboneElement 0..*   Clinical procedures performed  
sequence positiveInt 1..1 * Procedure instance identifier  
type CodeableConcept 0..*   Category of Procedure Example Procedure Type Codes ( Example )  
date dateTime 0..1   When the procedure was performed  
procedure[x]   1..1 * Specific clinical procedure ICD-10 Procedure Codes ( Example )  
procedureCodeableConcept CodeableConcept        
procedureReference Reference(Procedure)        
udi Reference(Device) 0..*   Unique device identifier  
precedence positiveInt 0..1   Precedence (primary, secondary, etc.)  
insurance BackboneElement 1..* * Patient insurance information  
focal boolean 1..1 * Coverage to be used for adjudication  
coverage Reference(Coverage) 1..1 * Insurance information  
preAuthRef string 0..*   Prior authorization reference number  
accident BackboneElement 0..1   Details of the event  
date date 0..1   When the incident occurred  
type CodeableConcept 0..1   The nature of the accident V3 Value SetActIncidentCode ( Extensible )  
location[x]   0..1   Where the event occurred  
locationAddress Address        
locationReference Reference(Location)        
item BackboneElement 0..*   Product or service provided  
sequence positiveInt 1..1 * Item instance identifier  
careTeamSequence positiveInt 0..*   Applicable care team members  
diagnosisSequence positiveInt 0..*   Applicable diagnoses  
procedureSequence positiveInt 0..*   Applicable procedures  
informationSequence positiveInt 0..*   Applicable exception and supporting information  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Product or service billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
serviced[x]   0..1   Date or dates of service or product delivery  
servicedDate date        
servicedPeriod Period        
location[x]   0..1   Place of service or where product was supplied Example Service Place Codes ( Example )  
locationCodeableConcept CodeableConcept        
locationAddress Address        
locationReference Reference(Location)        
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
bodySite CodeableConcept 0..1   Anatomical location Oral Site Codes ( Example )  
subSite CodeableConcept 0..*   Anatomical sub-location Surface Codes ( Example )  
encounter Reference(Encounter) 0..*   Encounters related to this billed item  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication BackboneElement 0..*   Adjudication details  
category CodeableConcept 1..1 * Type of adjudication information Adjudication Value Codes ( Example )  
reason CodeableConcept 0..1   Explanation of adjudication outcome Adjudication Reason Codes ( Example )  
amount Money 0..1   Monetary amount  
value decimal 0..1   Non-monitary value  
detail BackboneElement 0..*   Additional items  
sequence positiveInt 1..1 * Product or service provided  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Detail level adjudication details  
subDetail BackboneElement 0..*   Additional items  
sequence positiveInt 1..1 * Product or service provided  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Subdetail level adjudication details  
addItem BackboneElement 0..*   Insurer added line items  
itemSequence positiveInt 0..*   Item sequence number  
detailSequence positiveInt 0..*   Detail sequence number  
subDetailSequence positiveInt 0..*   Subdetail sequence number  
provider Reference(Practitioner | PractitionerRole | Organization) 0..*   Authorized providers  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
serviced[x]   0..1   Date or dates of service or product delivery  
servicedDate date        
servicedPeriod Period        
location[x]   0..1   Place of service or where product was supplied Example Service Place Codes ( Example )  
locationCodeableConcept CodeableConcept        
locationAddress Address        
locationReference Reference(Location)        
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
bodySite CodeableConcept 0..1   Anatomical location Oral Site Codes ( Example )  
subSite CodeableConcept 0..*   Anatomical sub-location Surface Codes ( Example )  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
detail BackboneElement 0..*   Insurer added line items  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
subDetail BackboneElement 0..*   Insurer added line items  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
adjudication see adjudication 0..*   Header-level adjudication  
total BackboneElement 0..*   Adjudication totals  
category CodeableConcept 1..1 * Type of adjudication information Adjudication Value Codes ( Example )  
amount Money 1..1 * Financial total for the category  
payment BackboneElement 0..1   Payment Details  
type CodeableConcept 0..1   Partial or complete payment Example Payment Type Codes ( Example )  
adjustment Money 0..1   Payment adjustment for non-claim issues  
adjustmentReason CodeableConcept 0..1   Explanation for the variance Payment Adjustment Reason Codes ( Example )  
date date 0..1   Expected date of payment  
amount Money 0..1   Payable amount after adjustment  
identifier Identifier 0..1   Business identifier for the payment  
formCode CodeableConcept 0..1   Printed form identifier Forms ( Example )  
form Attachment 0..1   Printed reference or actual form  
processNote BackboneElement 0..*   Note concerning adjudication  
number positiveInt 0..1   Note instance identifier  
type code 0..1   display | print | printoper NoteType ( Required )  
text string 0..1   Note explanatory text  
language CodeableConcept 0..1   Language of the text Common Languages ( Preferred but limited to AllLanguages )  
benefitPeriod Period 0..1   When the benefits are applicable  
benefitBalance BackboneElement 0..*   Balance by Benefit Category  
category CodeableConcept 1..1 * Benefit classification Benefit Category Codes ( Example )  
excluded boolean 0..1   Excluded from the plan  
name string 0..1   Short name for the benefit  
description string 0..1   Description of the benefit or services covered  
network CodeableConcept 0..1   In or out of network Network Type Codes ( Example )  
unit CodeableConcept 0..1   Individual or family Unit Type Codes ( Example )  
term CodeableConcept 0..1   Annual or lifetime Benefit Term Codes ( Example )  
financial BackboneElement 0..*   Benefit Summary  
type CodeableConcept 1..1 * Benefit classification Benefit Type Codes ( Example )  
allowed[x]   0..1   Benefits allowed  
allowedUnsignedInt unsignedInt        
allowedString string        
allowedMoney Money        
used[x]   0..1   Benefits used  
usedUnsignedInt unsignedInt        
usedMoney Money        
ExplanationOfBenefit DomainResource     Explanation of Benefit resourceElements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension  
identifier Identifier 0..*   Business Identifier for the resource  
status code 1..1 * active | cancelled | draft | entered-in-error ExplanationOfBenefitStatus ( Required )  
type CodeableConcept 1..1 * Category or discipline Claim Type Codes ( Extensible )  
subType CodeableConcept 0..1   More granular claim type Example Claim SubType Codes ( Example )  
use code 1..1 * claim | preauthorization | predetermination Use ( Required )  
patient Reference(Patient) 1..1 * The recipient of the products and services  
billablePeriod Period 0..1   Relevant time frame for the claim  
created dateTime 1..1 * Response creation date  
enterer Reference(Practitioner | PractitionerRole) 0..1   Author of the claim  
insurer Reference(Organization) 1..1 * Party responsible for reimbursement  
provider Reference(Practitioner | PractitionerRole | Organization) 1..1 * Party responsible for the claim  
priority CodeableConcept 0..1   Desired processing urgency ProcessPriority ( Example )  
fundsReserveRequested CodeableConcept 0..1   For whom to reserve funds FundsReserve ( Example )  
fundsReserve CodeableConcept 0..1   Funds reserved status FundsReserve ( Example )  
related BackboneElement 0..*   Prior or corollary claims  
claim Reference(Claim) 0..1   Reference to the related claim  
relationship CodeableConcept 0..1   How the reference claim is related Example Related Claim Relationship Codes ( Example )  
reference Identifier 0..1   File or case reference  
prescription Reference(MedicationRequest VisionPrescription) 0..1   Prescription authorizing services or products
originalPrescription Reference(MedicationRequest) 0..1   Original prescription if superceded by fulfiller  
payee BackboneElement 0..1   Recipient of benefits payable  
type CodeableConcept 0..1   Category of recipient PayeeType ( Example )  
party Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) 0..1   Recipient reference  
referral Reference(ServiceRequest) 0..1   Treatment Referral  
facility Reference(Location) 0..1   Servicing Facility  
claim Reference(Claim) 0..1   Claim reference  
claimResponse Reference(ClaimResponse) 0..1   Claim response reference  
outcome code 1..1 * queued | complete | error | partial Claim Processing Codes ( Required )  
disposition string 0..1   Disposition Message  
preAuthRef string 0..*   Preauthorization reference  
preAuthRefPeriod Period 0..*   Preauthorization in-effect period  
careTeam BackboneElement 0..*   Care Team members  
sequence positiveInt 1..1 * Order of care team  
provider Reference(Practitioner | PractitionerRole | Organization) 1..1 * Practitioner or organization  
responsible boolean 0..1   Indicator of the lead practitioner  
role CodeableConcept 0..1   Function within the team Claim Care Team Role Codes ( Example )  
qualification CodeableConcept 0..1   Practitioner credential or specialization Example Provider Qualification Codes ( Example )  
supportingInfo BackboneElement 0..*   Supporting information  
sequence positiveInt 1..1 * Information instance identifier  
category CodeableConcept 1..1 * Classification of the supplied information Claim Information Category Codes ( Example )  
code CodeableConcept 0..1   Type of information Exception Codes ( Example )  
timing[x]   0..1   When it occurred  
timingDate date        
timingPeriod Period        
value[x]   0..1   Data to be provided  
valueBoolean boolean        
valueString string        
valueQuantity Quantity        
valueAttachment Attachment        
valueReference Reference(Any)        
reason Coding 0..1   Explanation for the information Missing Tooth Reason Codes ( Example )  
diagnosis BackboneElement 0..*   Pertinent diagnosis information  
sequence positiveInt 1..1 * Diagnosis instance identifier  
diagnosis[x]   1..1 * Nature of illness or problem ICD-10 Codes ( Example )  
diagnosisCodeableConcept CodeableConcept        
diagnosisReference Reference(Condition)        
type CodeableConcept 0..*   Timing or nature of the diagnosis Example Diagnosis Type Codes ( Example )  
onAdmission CodeableConcept 0..1   Present on admission Example Diagnosis on Admission Codes ( Example )  
packageCode CodeableConcept 0..1   Package billing code Example Diagnosis Related Group Codes ( Example )  
procedure BackboneElement 0..*   Clinical procedures performed  
sequence positiveInt 1..1 * Procedure instance identifier  
type CodeableConcept 0..*   Category of Procedure Example Procedure Type Codes ( Example )  
date dateTime 0..1   When the procedure was performed  
procedure[x]   1..1 * Specific clinical procedure ICD-10 Procedure Codes ( Example )  
procedureCodeableConcept CodeableConcept        
procedureReference Reference(Procedure)        
udi Reference(Device) 0..*   Unique device identifier  
precedence positiveInt 0..1   Precedence (primary, secondary, etc.)  
insurance BackboneElement 1..* * Patient insurance information  
focal boolean 1..1 * Coverage to be used for adjudication  
coverage Reference(Coverage) 1..1 * Insurance information  
preAuthRef string 0..*   Prior authorization reference number  
accident BackboneElement 0..1   Details of the event  
date date 0..1   When the incident occurred  
type CodeableConcept 0..1   The nature of the accident V3 Value SetActIncidentCode ( Extensible )  
location[x]   0..1   Where the event occurred  
locationAddress Address        
locationReference Reference(Location)        
item BackboneElement 0..*   Product or service provided  
sequence positiveInt 1..1 * Item instance identifier  
careTeamSequence positiveInt 0..*   Applicable care team members  
diagnosisSequence positiveInt 0..*   Applicable diagnoses  
procedureSequence positiveInt 0..*   Applicable procedures  
informationSequence positiveInt 0..*   Applicable exception and supporting information  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Product or service billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
serviced[x]   0..1   Date or dates of service or product delivery  
servicedDate date        
servicedPeriod Period        
location[x]   0..1   Place of service or where product was supplied Example Service Place Codes ( Example )  
locationCodeableConcept CodeableConcept        
locationAddress Address        
locationReference Reference(Location)        
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
bodySite CodeableConcept 0..1   Anatomical location Oral Site Codes ( Example )  
subSite CodeableConcept 0..*   Anatomical sub-location Surface Codes ( Example )  
encounter Reference(Encounter) 0..*   Encounters related to this billed item  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication BackboneElement 0..*   Adjudication details  
category CodeableConcept 1..1 * Type of adjudication information Adjudication Value Codes ( Example )  
reason CodeableConcept 0..1   Explanation of adjudication outcome Adjudication Reason Codes ( Example )  
amount Money 0..1   Monetary amount  
value decimal 0..1   Non-monitary value  
detail BackboneElement 0..*   Additional items  
sequence positiveInt 1..1 * Product or service provided  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Detail level adjudication details  
subDetail BackboneElement 0..*   Additional items  
sequence positiveInt 1..1 * Product or service provided  
revenue CodeableConcept 0..1   Revenue or cost center code Example Revenue Center Codes ( Example )  
category CodeableConcept 0..1   Benefit classification Benefit Category Codes ( Example )  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
udi Reference(Device) 0..*   Unique device identifier  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Subdetail level adjudication details  
addItem BackboneElement 0..*   Insurer added line items  
itemSequence positiveInt 0..*   Item sequence number  
detailSequence positiveInt 0..*   Detail sequence number  
subDetailSequence positiveInt 0..*   Subdetail sequence number  
provider Reference(Practitioner | PractitionerRole | Organization) 0..*   Authorized providers  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
programCode CodeableConcept 0..*   Program the product or service is provided under Example Program Reason Codes ( Example )  
serviced[x]   0..1   Date or dates of service or product delivery  
servicedDate date        
servicedPeriod Period        
location[x]   0..1   Place of service or where product was supplied Example Service Place Codes ( Example )  
locationCodeableConcept CodeableConcept        
locationAddress Address        
locationReference Reference(Location)        
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
bodySite CodeableConcept 0..1   Anatomical location Oral Site Codes ( Example )  
subSite CodeableConcept 0..*   Anatomical sub-location Surface Codes ( Example )  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
detail BackboneElement 0..*   Insurer added line items  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
subDetail BackboneElement 0..*   Insurer added line items  
productOrService CodeableConcept 1..1 * Billing, service, product, or drug code USCLS Codes ( Example )  
modifier CodeableConcept 0..*   Service/Product billing modifiers Modifier type Codes ( Example )  
quantity SimpleQuantity 0..1   Count of products or services  
unitPrice Money 0..1   Fee, charge or cost per item  
factor decimal 0..1   Price scaling factor  
net Money 0..1   Total item cost  
noteNumber positiveInt 0..*   Applicable note numbers  
adjudication see adjudication 0..*   Added items adjudication  
adjudication see adjudication 0..*   Header-level adjudication  
total BackboneElement 0..*   Adjudication totals  
category CodeableConcept 1..1 * Type of adjudication information Adjudication Value Codes ( Example )  
amount Money 1..1 * Financial total for the category  
payment BackboneElement 0..1   Payment Details  
type CodeableConcept 0..1   Partial or complete payment Example Payment Type Codes ( Example )  
adjustment Money 0..1   Payment adjustment for non-claim issues  
adjustmentReason CodeableConcept 0..1   Explanation for the variance Payment Adjustment Reason Codes ( Example )  
date date 0..1   Expected date of payment  
amount Money 0..1   Payable amount after adjustment  
identifier Identifier 0..1   Business identifier for the payment  
formCode CodeableConcept 0..1   Printed form identifier Forms ( Example )  
form Attachment 0..1   Printed reference or actual form  
processNote BackboneElement 0..*   Note concerning adjudication  
number positiveInt 0..1   Note instance identifier  
type code 0..1   display | print | printoper NoteType ( Required )  
text string 0..1   Note explanatory text  
language CodeableConcept 0..1   Language of the text Common Languages ( Preferred but limited to AllLanguages )  
benefitPeriod Period 0..1   When the benefits are applicable  
benefitBalance BackboneElement 0..*   Balance by Benefit Category  
category CodeableConcept 1..1 * Benefit classification Benefit Category Codes ( Example )  
excluded boolean 0..1   Excluded from the plan  
name string 0..1   Short name for the benefit  
description string 0..1   Description of the benefit or services covered  
network CodeableConcept 0..1   In or out of network Network Type Codes ( Example )  
unit CodeableConcept 0..1   Individual or family Unit Type Codes ( Example )  
term CodeableConcept 0..1   Annual or lifetime Benefit Term Codes ( Example )  
financial BackboneElement 0..*   Benefit Summary  
type CodeableConcept 1..1 * Benefit classification Benefit Type Codes ( Example )  
allowed[x]   0..1   Benefits allowed  
allowedUnsignedInt unsignedInt        
allowedString string        
allowedMoney Money        
used[x]   0..1   Benefits used  
usedUnsignedInt unsignedInt        
usedMoney Money        

Interactions

Read

Get a ExplanationOfBenefit entry by id

GET /ExplanationOfBenefit/:id

Example

Request

https://r4cert.medicasoft.us/api/fhir/ExplanationOfBenefit/6b8efb9a-ed29-4a43-b79a-ba2d49fea9b3

Response

{
  "timestamp": 1749197941618,
  "lastUpdated": "2025-06-06T08:19:01.825Z",
  "version": 1,
  "type": "ExplanationOfBenefit",
  "id": "6b8efb9a-ed29-4a43-b79a-ba2d49fea9b3",
  "explanationofbenefit": {
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "submitted",
              "system": "http://medicasoft.com/nxt/adjudication",
              "display": "Billed Amount"
            }
          ]
        },
        "amount": {
          "value": 916.4
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligible",
              "system": "http://medicasoft.com/nxt/adjudication",
              "display": "Allowed Amount"
            }
          ]
        },
        "amount": {
          "value": 938.88
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit",
              "system": "http://medicasoft.com/nxt/adjudication",
              "display": "Payment Amount"
            }
          ]
        },
        "amount": {
          "value": 811.09
        }
      }
    ],
    "careTeam": [
      {
        "qualification": {
          "coding": [
            {
              "code": "193400000X"
            }
          ]
        }
      }
    ],
    "payment": {
      "type": {
        "coding": [
          {
            "code": "P",
            "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype"
          }
        ]
      }
    },
    "status": "P",
    "total": [
      {
        "category": {
          "coding": [
            {
              "code": "benefit",
              "system": "http://medicasoft.com/nxt/adjudication",
              "display": "Total Benefit Amount"
            }
          ]
        },
        "amount": {
          "value": 811.09
        }
      }
    ],
    "type": {
      "coding": [
        {
          "code": "oral",
          "systemCode": "http://terminology.hl7.org/CodeSystem/claim-type|oral"
        }
      ]
    },
    "use": "claim",
    "patient": {
      "reference": "Patient/nc.hhs|HZ DXVKOMD"
    },
    "billablePeriod": {
      "start": "2024-04-30T21:00:00.000Z",
      "end": "2024-12-01T22:00:00.000Z"
    }
  }
}

Query ExplanationOfBenefit resources

GET /ExplanationOfBenefit?:query_parameters

Parameters

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

Errors

Code Description
400 Invalid parameters
404 Resource not found