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Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Подробное описание элементов ресурса ExplanationOfBenefit.

ExplanationOfBenefit
Element IdExplanationOfBenefit
Definition

Данный ресурс обеспечивает: детализацию страхового требования (claim); детализацию судебного решения (adjudication) из обработки Claim; и, факультативно, информацию по остатку на счете, для информирования подписчика (subscriber) о предоставленных льготах/выплатах (benefits). Explanation of Benefit - это отчёт, высылаемый медицинскими страховыми компаниями своим клиентам, с пояснениями, какое медицинское лечение и/или услуги были оплачены от их имени (прим. пер.).

Control0..*
TypeDomainResource
Alternate NamesEOB
ExplanationOfBenefit.identifier
Element IdExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows EOBs to be distinguished and referenced.

ExplanationOfBenefit.status
Element IdExplanationOfBenefit.status
Definition

The status of the resource instance.

Control1..1
Terminology BindingExplanationOfBenefitStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

ExplanationOfBenefit.type
Element IdExplanationOfBenefit.type
Definition

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

Control1..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Summarytrue
Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

ExplanationOfBenefit.subType
Element IdExplanationOfBenefit.subType
Definition

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

Control0..1
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

Может содержать коды локального типа выставления счёта, такие как UB-04-код типа выставления счёта США.

ExplanationOfBenefit.use
Element IdExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Control1..1
Terminology BindingUse (Required)
Typecode
Requirements

This element is required to understand the nature of the request for adjudication.

Summarytrue
ExplanationOfBenefit.patient
Element IdExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimburement is sought.

Control1..1
TypeReference(Patient)
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Summarytrue
ExplanationOfBenefit.billablePeriod
Element IdExplanationOfBenefit.billablePeriod
Definition

The period for which charges are being submitted.

Control0..1
TypePeriod
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Summarytrue
Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

ExplanationOfBenefit.created
Element IdExplanationOfBenefit.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Summarytrue
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

ExplanationOfBenefit.enterer
Element IdExplanationOfBenefit.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Some jurisdictions require the contact information for personnel completing claims.

ExplanationOfBenefit.insurer
Element IdExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Control1..1
TypeReference(Organization)
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Summarytrue
ExplanationOfBenefit.provider
Element IdExplanationOfBenefit.provider
Definition

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

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization)
Summarytrue
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

ExplanationOfBenefit.priority
Element IdExplanationOfBenefit.priority
Definition

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

Control0..1
Terminology BindingProcessPriority :
TypeCodeableConcept
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

ExplanationOfBenefit.fundsReserveRequested
Element IdExplanationOfBenefit.fundsReserveRequested
Definition

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

Control0..1
Terminology BindingFundsReserve (Example)
TypeCodeableConcept
Requirements

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Alternate NamesFund pre-allocation
Comments

This field is only used for preauthorizations.

ExplanationOfBenefit.fundsReserve
Element IdExplanationOfBenefit.fundsReserve
Definition

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

Control0..1
Terminology BindingFundsReserve (Example)
TypeCodeableConcept
Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Comments

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

ExplanationOfBenefit.related
Element IdExplanationOfBenefit.related
Definition

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

Control0..*
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Comments

For example, for the original treatment and follow-up exams.

ExplanationOfBenefit.related.claim
Element IdExplanationOfBenefit.related.claim
Definition

Reference to a related claim.

Control0..1
TypeReference(Claim)
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

ExplanationOfBenefit.related.relationship
Element IdExplanationOfBenefit.related.relationship
Definition

A code to convey how the claims are related.

Control0..1
Terminology BindingExample Related Claim Relationship Codes (Example)
TypeCodeableConcept
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

ExplanationOfBenefit.related.reference
Element IdExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Control0..1
TypeIdentifier
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Comments

For example, Property/Casualty insurer claim # or Workers Compensation case # .

ExplanationOfBenefit.prescription
Element IdExplanationOfBenefit.prescription
Definition

Рецепт на фармацевтические или продукты для коррекции зрения.

Control0..1
TypeReference(MedicationRequest | VisionPrescription)
Requirements

Required to authorize the dispensing of controlled substances and devices.

ExplanationOfBenefit.originalPrescription
Element IdExplanationOfBenefit.originalPrescription
Definition

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

Control0..1
TypeReference(MedicationRequest)
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Comments

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

ExplanationOfBenefit.payee
Element IdExplanationOfBenefit.payee
Definition

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

Control0..1
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider are choose to pay the subscriber instead.

ExplanationOfBenefit.payee.type
Element IdExplanationOfBenefit.payee.type
Definition

Тип стороны, которой возмещаются затраты: подписчик, поставщик, другое.

Control0..1
Terminology BindingPayeeType (Example)
TypeCodeableConcept
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

ExplanationOfBenefit.payee.party
Element IdExplanationOfBenefit.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Comments

Not required if the payee is 'subscriber' or 'provider'.

ExplanationOfBenefit.referral
Element IdExplanationOfBenefit.referral
Definition

A reference to a referral resource.

Control0..1
TypeReference(ServiceRequest)
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments

Ресурс ReferralRequest, в котором перечислены дата, врач, обоснование и другая вспомогательная информация.

ExplanationOfBenefit.facility
Element IdExplanationOfBenefit.facility
Definition

Учреждение, где были предоставлены услуги.

Control0..1
TypeReference(Location)
Requirements

Insurance adjudication can be dependant on where services were delivered.

ExplanationOfBenefit.claim
Element IdExplanationOfBenefit.claim
Definition

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

Control0..1
TypeReference(Claim)
Requirements

To provide a link to the original adjudication request.

ExplanationOfBenefit.claimResponse
Element IdExplanationOfBenefit.claimResponse
Definition

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

Control0..1
TypeReference(ClaimResponse)
Requirements

To provide a link to the original adjudication response.

ExplanationOfBenefit.outcome
Element IdExplanationOfBenefit.outcome
Definition

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

Control1..1
Terminology BindingClaim Processing Codes (Required)
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Summarytrue
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

ExplanationOfBenefit.disposition
Element IdExplanationOfBenefit.disposition
Definition

A human readable description of the status of the adjudication.

Control0..1
Typestring
Requirements

Provided for user display.

ExplanationOfBenefit.preAuthRef
Element IdExplanationOfBenefit.preAuthRef
Definition

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

Control0..*
Typestring
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Comments

This value is only present on preauthorization adjudications.

ExplanationOfBenefit.preAuthRefPeriod
Element IdExplanationOfBenefit.preAuthRefPeriod
Definition

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

Control0..*
TypePeriod
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Comments

This value is only present on preauthorization adjudications.

ExplanationOfBenefit.careTeam
Element IdExplanationOfBenefit.careTeam
Definition

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

Control0..*
Requirements

Common to identify the responsible and supporting practitioners.

ExplanationOfBenefit.careTeam.sequence
Element IdExplanationOfBenefit.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

ExplanationOfBenefit.careTeam.provider
Element IdExplanationOfBenefit.careTeam.provider
Definition

Member of the team who provided the product or service.

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Often a regulatory requirement to specify the responsible provider.

ExplanationOfBenefit.careTeam.responsible
Element IdExplanationOfBenefit.careTeam.responsible
Definition

The party who is billing and/or responsible for the claimed products or services.

Control0..1
Typeboolean
Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Comments

Responsible might not be required when there is only a single provider listed.

ExplanationOfBenefit.careTeam.role
Element IdExplanationOfBenefit.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Control0..1
Terminology BindingClaim Care Team Role Codes (Example)
TypeCodeableConcept
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

Role might not be required when there is only a single provider listed.

ExplanationOfBenefit.careTeam.qualification
Element IdExplanationOfBenefit.careTeam.qualification
Definition

The qualification of the practitioner which is applicable for this service.

Control0..1
Terminology BindingExample Provider Qualification Codes (Example)
TypeCodeableConcept
Requirements

Need to specify which qualification a provider is delivering the product or service under.

ExplanationOfBenefit.supportingInfo
Element IdExplanationOfBenefit.supportingInfo
Definition

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

Control0..*
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Often there are multiple jurisdiction specific valuesets which are required.

ExplanationOfBenefit.supportingInfo.sequence
Element IdExplanationOfBenefit.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

ExplanationOfBenefit.supportingInfo.category
Element IdExplanationOfBenefit.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
Terminology BindingClaim Information Category Codes (Example)
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

ExplanationOfBenefit.supportingInfo.code
Element IdExplanationOfBenefit.supportingInfo.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
Terminology BindingException Codes (Example)
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Comments

Может содержать коды локального типа выставления счёта, такие как UB-04-код типа выставления счёта США.

ExplanationOfBenefit.supportingInfo.timing[x]
Element IdExplanationOfBenefit.supportingInfo.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
ExplanationOfBenefit.supportingInfo.value[x]
Element IdExplanationOfBenefit.supportingInfo.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
Typeboolean|string|Quantity|Attachment|Reference(Any)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

ExplanationOfBenefit.supportingInfo.reason
Element IdExplanationOfBenefit.supportingInfo.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
Terminology BindingMissing Tooth Reason Codes (Example)
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

ExplanationOfBenefit.diagnosis
Element IdExplanationOfBenefit.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Control0..*
Requirements

Required for the adjudication by provided context for the services and product listed.

ExplanationOfBenefit.diagnosis.sequence
Element IdExplanationOfBenefit.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

ExplanationOfBenefit.diagnosis.diagnosis[x]
Element IdExplanationOfBenefit.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Control1..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Provides health context for the evaluation of the products and/or services.

ExplanationOfBenefit.diagnosis.type
Element IdExplanationOfBenefit.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Control0..*
Terminology BindingExample Diagnosis Type Codes (Example)
TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

For example: admitting, primary, secondary, discharge.

ExplanationOfBenefit.diagnosis.onAdmission
Element IdExplanationOfBenefit.diagnosis.onAdmission
Definition

Indication of whether the diagnosis was present on admission to a facility.

Control0..1
Terminology BindingExample Diagnosis on Admission Codes (Example)
TypeCodeableConcept
Requirements

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

ExplanationOfBenefit.diagnosis.packageCode
Element IdExplanationOfBenefit.diagnosis.packageCode
Definition

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Control0..1
Terminology BindingExample Diagnosis Related Group Codes (Example)
TypeCodeableConcept
Requirements

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Comments

For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

ExplanationOfBenefit.procedure
Element IdExplanationOfBenefit.procedure
Definition

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

Control0..*
Requirements

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

ExplanationOfBenefit.procedure.sequence
Element IdExplanationOfBenefit.procedure.sequence
Definition

A number to uniquely identify procedure entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to claim details.

ExplanationOfBenefit.procedure.date
Element IdExplanationOfBenefit.procedure.date
Definition

Дата и, необязательно, время, когда была выполнена процедура.

Control0..1
TypedateTime
Requirements

Required for auditing purposes.

ExplanationOfBenefit.procedure.procedure[x]
Element IdExplanationOfBenefit.procedure.procedure[x]
Definition

The code or reference to a Procedure resource which identifies the clinical intervention performed.

Control1..1
Terminology BindingICD-10 Procedure Codes (Example)
TypeCodeableConcept|Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

This identifies the actual clinical procedure.

ExplanationOfBenefit.procedure.udi
Element IdExplanationOfBenefit.procedure.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

ExplanationOfBenefit.precedence
Element IdExplanationOfBenefit.precedence
Definition

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

Control0..1
TypepositiveInt
Requirements

Needed to coordinate between multiple EOBs for the same suite of services.

ExplanationOfBenefit.insurance
Element IdExplanationOfBenefit.insurance
Definition

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

Control1..*
Requirements

At least one insurer is required for a claim to be a claim.

Summarytrue
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

ExplanationOfBenefit.insurance.focal
Element IdExplanationOfBenefit.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Control1..1
Typeboolean
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Summarytrue
Comments

A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

ExplanationOfBenefit.insurance.coverage
Element IdExplanationOfBenefit.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Control1..1
TypeReference(Coverage)
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Summarytrue
ExplanationOfBenefit.insurance.preAuthRef
Element IdExplanationOfBenefit.insurance.preAuthRef
Definition

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Control0..*
Typestring
Requirements

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Comments

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

ExplanationOfBenefit.accident
Element IdExplanationOfBenefit.accident
Definition

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

Control0..1
Requirements

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

ExplanationOfBenefit.accident.date
Element IdExplanationOfBenefit.accident.date
Definition

Date of an accident event related to the products and services contained in the claim.

Control0..1
Typedate
Requirements

Required for audit purposes and adjudication.

Comments

The date of the accident has to preceed the dates of the products and services but within a reasonable timeframe.

ExplanationOfBenefit.accident.type
Element IdExplanationOfBenefit.accident.type
Definition

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Control0..1
Terminology BindingV3 Value SetActIncidentCode (Extensible)
TypeCodeableConcept
Requirements

Страховое покрытие может зависеть от несчастного случая.

ExplanationOfBenefit.accident.location[x]
Element IdExplanationOfBenefit.accident.location[x]
Definition

The physical location of the accident event.

Control0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required for audit purposes and determination of applicable insurance liability.

ExplanationOfBenefit.item
Element IdExplanationOfBenefit.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Control0..*
Requirements

The items to be processed for adjudication.

ExplanationOfBenefit.item.sequence
Element IdExplanationOfBenefit.item.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

ExplanationOfBenefit.item.careTeamSequence
Element IdExplanationOfBenefit.item.careTeamSequence
Definition

CareTeam members related to this service or product.

Control0..*
TypepositiveInt
Requirements

Need to identify the individuals and their roles in the provision of the product or service.

ExplanationOfBenefit.item.diagnosisSequence
Element IdExplanationOfBenefit.item.diagnosisSequence
Definition

Diagnoses applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to related the product or service to the associated diagnoses.

ExplanationOfBenefit.item.procedureSequence
Element IdExplanationOfBenefit.item.procedureSequence
Definition

Procedures applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to provide any listed specific procedures to support the product or service being claimed.

ExplanationOfBenefit.item.informationSequence
Element IdExplanationOfBenefit.item.informationSequence
Definition

Exceptions, special conditions and supporting information applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to reference the supporting information items that relate directly to this product or service.

ExplanationOfBenefit.item.revenue
Element IdExplanationOfBenefit.item.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

ExplanationOfBenefit.item.category
Element IdExplanationOfBenefit.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.productOrService
Element IdExplanationOfBenefit.item.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.modifier
Element IdExplanationOfBenefit.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.item.programCode
Element IdExplanationOfBenefit.item.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.serviced[x]
Element IdExplanationOfBenefit.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

ExplanationOfBenefit.item.location[x]
Element IdExplanationOfBenefit.item.location[x]
Definition

Where the product or service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

ExplanationOfBenefit.item.quantity
Element IdExplanationOfBenefit.item.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.item.unitPrice
Element IdExplanationOfBenefit.item.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.item.factor
Element IdExplanationOfBenefit.item.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.net
Element IdExplanationOfBenefit.item.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.udi
Element IdExplanationOfBenefit.item.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

ExplanationOfBenefit.item.bodySite
Element IdExplanationOfBenefit.item.bodySite
Definition

Физическое расположение на пациенте места оказания услуги (конечность, зуб и т. п.).

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

ExplanationOfBenefit.item.subSite
Element IdExplanationOfBenefit.item.subSite
Definition

Участок или поверхность тела, например область конечности или поверхности зуба.

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

ExplanationOfBenefit.item.encounter
Element IdExplanationOfBenefit.item.encounter
Definition

A billed item may include goods or services provided in multiple encounters.

Control0..*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

ExplanationOfBenefit.item.noteNumber
Element IdExplanationOfBenefit.item.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.item.adjudication
Element IdExplanationOfBenefit.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Control0..*
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

ExplanationOfBenefit.item.adjudication.category
Element IdExplanationOfBenefit.item.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

ExplanationOfBenefit.item.adjudication.reason
Element IdExplanationOfBenefit.item.adjudication.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Control0..1
Terminology BindingAdjudication Reason Codes (Example)
TypeCodeableConcept
Requirements

To support understanding of variance from adjudication expectations.

Comments

For example may indicate that the funds for this benefit type have been exhausted.

ExplanationOfBenefit.item.adjudication.amount
Element IdExplanationOfBenefit.item.adjudication.amount
Definition

Monetary amount associated with the category.

Control0..1
TypeMoney
Requirements

Most adjuciation categories convey a monetary amount.

Comments

For example: amount submitted, eligible amount, co-payment, and benefit payable.

ExplanationOfBenefit.item.adjudication.value
Element IdExplanationOfBenefit.item.adjudication.value
Definition

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Control0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

ExplanationOfBenefit.item.detail
Element IdExplanationOfBenefit.item.detail
Definition

Second-tier of Товары и услуги.

Control0..*
ExplanationOfBenefit.item.detail.sequence
Element IdExplanationOfBenefit.item.detail.sequence
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control1..1
TypepositiveInt
Requirements

The items to be processed for adjudication.

ExplanationOfBenefit.item.detail.revenue
Element IdExplanationOfBenefit.item.detail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

ExplanationOfBenefit.item.detail.category
Element IdExplanationOfBenefit.item.detail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.detail.productOrService
Element IdExplanationOfBenefit.item.detail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.detail.modifier
Element IdExplanationOfBenefit.item.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.item.detail.programCode
Element IdExplanationOfBenefit.item.detail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.detail.quantity
Element IdExplanationOfBenefit.item.detail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.item.detail.unitPrice
Element IdExplanationOfBenefit.item.detail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.item.detail.factor
Element IdExplanationOfBenefit.item.detail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.detail.net
Element IdExplanationOfBenefit.item.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.detail.udi
Element IdExplanationOfBenefit.item.detail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

ExplanationOfBenefit.item.detail.noteNumber
Element IdExplanationOfBenefit.item.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.item.detail.adjudication
Element IdExplanationOfBenefit.item.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.item.detail.subDetail
Element IdExplanationOfBenefit.item.detail.subDetail
Definition

Third-tier of goods and services.

Control0..*
ExplanationOfBenefit.item.detail.subDetail.sequence
Element IdExplanationOfBenefit.item.detail.subDetail.sequence
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control1..1
TypepositiveInt
Requirements

The items to be processed for adjudication.

ExplanationOfBenefit.item.detail.subDetail.revenue
Element IdExplanationOfBenefit.item.detail.subDetail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

ExplanationOfBenefit.item.detail.subDetail.category
Element IdExplanationOfBenefit.item.detail.subDetail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.item.detail.subDetail.productOrService
Element IdExplanationOfBenefit.item.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.item.detail.subDetail.modifier
Element IdExplanationOfBenefit.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.item.detail.subDetail.programCode
Element IdExplanationOfBenefit.item.detail.subDetail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.item.detail.subDetail.quantity
Element IdExplanationOfBenefit.item.detail.subDetail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.item.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.item.detail.subDetail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.item.detail.subDetail.factor
Element IdExplanationOfBenefit.item.detail.subDetail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.item.detail.subDetail.net
Element IdExplanationOfBenefit.item.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.item.detail.subDetail.udi
Element IdExplanationOfBenefit.item.detail.subDetail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

ExplanationOfBenefit.item.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.item.detail.subDetail.adjudication
Element IdExplanationOfBenefit.item.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem
Element IdExplanationOfBenefit.addItem
Definition

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

Control0..*
Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

ExplanationOfBenefit.addItem.itemSequence
Element IdExplanationOfBenefit.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

Control0..*
TypepositiveInt
Requirements

Provides references to the claim items.

ExplanationOfBenefit.addItem.detailSequence
Element IdExplanationOfBenefit.addItem.detailSequence
Definition

The sequence number of the details within the claim item which this line is intended to replace.

Control0..*
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

ExplanationOfBenefit.addItem.subDetailSequence
Element IdExplanationOfBenefit.addItem.subDetailSequence
Definition

The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

Control0..*
TypepositiveInt
Requirements

Provides references to the claim sub-details within the claim detail.

ExplanationOfBenefit.addItem.provider
Element IdExplanationOfBenefit.addItem.provider
Definition

The providers who are authorized for the services rendered to the patient.

Control0..*
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

ExplanationOfBenefit.addItem.productOrService
Element IdExplanationOfBenefit.addItem.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.modifier
Element IdExplanationOfBenefit.addItem.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.programCode
Element IdExplanationOfBenefit.addItem.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

ExplanationOfBenefit.addItem.serviced[x]
Element IdExplanationOfBenefit.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

ExplanationOfBenefit.addItem.location[x]
Element IdExplanationOfBenefit.addItem.location[x]
Definition

Where the product or service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

ExplanationOfBenefit.addItem.quantity
Element IdExplanationOfBenefit.addItem.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.addItem.unitPrice
Element IdExplanationOfBenefit.addItem.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.addItem.factor
Element IdExplanationOfBenefit.addItem.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.net
Element IdExplanationOfBenefit.addItem.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.bodySite
Element IdExplanationOfBenefit.addItem.bodySite
Definition

Физическое расположение на пациенте места оказания услуги (конечность, зуб и т. п.).

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

ExplanationOfBenefit.addItem.subSite
Element IdExplanationOfBenefit.addItem.subSite
Definition

Участок или поверхность тела, например область конечности или поверхности зуба.

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

ExplanationOfBenefit.addItem.noteNumber
Element IdExplanationOfBenefit.addItem.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.addItem.adjudication
Element IdExplanationOfBenefit.addItem.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem.detail
Element IdExplanationOfBenefit.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Control0..*
ExplanationOfBenefit.addItem.detail.productOrService
Element IdExplanationOfBenefit.addItem.detail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.detail.modifier
Element IdExplanationOfBenefit.addItem.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.detail.quantity
Element IdExplanationOfBenefit.addItem.detail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.addItem.detail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.addItem.detail.factor
Element IdExplanationOfBenefit.addItem.detail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.detail.net
Element IdExplanationOfBenefit.addItem.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.detail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.addItem.detail.adjudication
Element IdExplanationOfBenefit.addItem.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.addItem.detail.subDetail
Element IdExplanationOfBenefit.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Control0..*
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
Element IdExplanationOfBenefit.addItem.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

ExplanationOfBenefit.addItem.detail.subDetail.modifier
Element IdExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

ExplanationOfBenefit.addItem.detail.subDetail.quantity
Element IdExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Element IdExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

ExplanationOfBenefit.addItem.detail.subDetail.factor
Element IdExplanationOfBenefit.addItem.detail.subDetail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

ExplanationOfBenefit.addItem.detail.subDetail.net
Element IdExplanationOfBenefit.addItem.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Element IdExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Element IdExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
ExplanationOfBenefit.adjudication
Element IdExplanationOfBenefit.adjudication
Definition

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

Control0..*
TypeSee ExplanationOfBenefit.item.adjudication
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

ExplanationOfBenefit.total
Element IdExplanationOfBenefit.total
Definition

Categorized monetary totals for the adjudication.

Control0..*
Requirements

To provide the requestor with financial totals by category for the adjudication.

Summarytrue
Comments

Totals for amounts submitted, co-pays, benefits payable etc.

ExplanationOfBenefit.total.category
Element IdExplanationOfBenefit.total.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the type of total provided.

Summarytrue
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

ExplanationOfBenefit.total.amount
Element IdExplanationOfBenefit.total.amount
Definition

Monetary total amount associated with the category.

Control1..1
TypeMoney
Requirements

Needed to convey the total monetary amount.

Summarytrue
ExplanationOfBenefit.payment
Element IdExplanationOfBenefit.payment
Definition

Payment details for the adjudication of the claim.

Control0..1
Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

ExplanationOfBenefit.payment.type
Element IdExplanationOfBenefit.payment.type
Definition

Whether this represents partial or complete payment of the benefits payable.

Control0..1
Terminology BindingExample Payment Type Codes (Example)
TypeCodeableConcept
Requirements

To advise the requestor when the insurer believes all payments to have been completed.

ExplanationOfBenefit.payment.adjustment
Element IdExplanationOfBenefit.payment.adjustment
Definition

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

Control0..1
TypeMoney
Requirements

To advise the requestor of adjustments applied to the payment.

Comments

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

ExplanationOfBenefit.payment.adjustmentReason
Element IdExplanationOfBenefit.payment.adjustmentReason
Definition

Причина корректировки платежа.

Control0..1
Terminology BindingPayment Adjustment Reason Codes (Example)
TypeCodeableConcept
Requirements

Needed to clarify the monetary adjustment.

ExplanationOfBenefit.payment.date
Element IdExplanationOfBenefit.payment.date
Definition

Estimated date the payment will be issued or the actual issue date of payment.

Control0..1
Typedate
Requirements

To advise the payee when payment can be expected.

ExplanationOfBenefit.payment.amount
Element IdExplanationOfBenefit.payment.amount
Definition

Benefits Сумма, подлежащая оплате, меньшая, чем любая корректировка оплаты.

Control0..1
TypeMoney
Requirements

Needed to provide the actual payment amount.

ExplanationOfBenefit.payment.identifier
Element IdExplanationOfBenefit.payment.identifier
Definition

Issuer's unique identifier for the payment instrument.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Requirements

Enable the receiver to reconcile when payment received.

Comments

For example: EFT number or check number.

ExplanationOfBenefit.formCode
Element IdExplanationOfBenefit.formCode
Definition

A code for Форма, которую необходимо использовать для печати данного содержимого.

Control0..1
Terminology BindingForms (Example)
TypeCodeableConcept
Requirements

Needed to specify the specific form used for producing output for this response.

Comments

May be needed to identify specific jurisdictional forms.

ExplanationOfBenefit.form
Element IdExplanationOfBenefit.form
Definition

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

Control0..1
TypeAttachment
Requirements

Needed to include the specific form used for producing output for this response.

Comments

Needed to permit insurers to include the actual form.

ExplanationOfBenefit.processNote
Element IdExplanationOfBenefit.processNote
Definition

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

Control0..*
Requirements

Provides the insurer specific textual explanations associated with the processing.

ExplanationOfBenefit.processNote.number
Element IdExplanationOfBenefit.processNote.number
Definition

A number to uniquely identify a note entry.

Control0..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link from adjudications.

ExplanationOfBenefit.processNote.type
Element IdExplanationOfBenefit.processNote.type
Definition

The business purpose of the Текст примечания.

Control0..1
Terminology BindingNoteType (Required)
Typecode
Requirements

To convey the expectation for when the text is used.

ExplanationOfBenefit.processNote.text
Element IdExplanationOfBenefit.processNote.text
Definition

The explanation or description associated with the processing.

Control0..1
Typestring
Requirements

Required to provide human readable explanation.

ExplanationOfBenefit.processNote.language
Element IdExplanationOfBenefit.processNote.language
Definition

A code to define the language used in the text of the note.

Control0..1
Terminology BindingLanguage (Preferred but limited to Language)
TypeCodeableConcept
Requirements

Note text may vary from the resource defined language.

Comments

Only requred if the language is different from the resource language.

ExplanationOfBenefit.benefitPeriod
Element IdExplanationOfBenefit.benefitPeriod
Definition

The term of the benefits documented in this response.

Control0..1
TypePeriod
Requirements

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Comments

Not applicable when use=claim.

ExplanationOfBenefit.benefitBalance
Element IdExplanationOfBenefit.benefitBalance
Definition

Balance by Benefit Category.

Control0..*
ExplanationOfBenefit.benefitBalance.category
Element IdExplanationOfBenefit.benefitBalance.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control1..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

ExplanationOfBenefit.benefitBalance.excluded
Element IdExplanationOfBenefit.benefitBalance.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Control0..1
Typeboolean
Requirements

Needed to identify items that are specifically excluded from the coverage.

ExplanationOfBenefit.benefitBalance.name
Element IdExplanationOfBenefit.benefitBalance.name
Definition

A short name or tag for the benefit.

Control0..1
Typestring
Requirements

Required to align with other plan names.

Comments

For example: MED01, or DENT2.

ExplanationOfBenefit.benefitBalance.description
Element IdExplanationOfBenefit.benefitBalance.description
Definition

A richer description of the benefit or services covered.

Control0..1
Typestring
Requirements

Needed for human readable reference.

Comments

For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

ExplanationOfBenefit.benefitBalance.network
Element IdExplanationOfBenefit.benefitBalance.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Control0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
Requirements

Needed as in or out of network providers are treated differently under the coverage.

ExplanationOfBenefit.benefitBalance.unit
Element IdExplanationOfBenefit.benefitBalance.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Control0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

ExplanationOfBenefit.benefitBalance.term
Element IdExplanationOfBenefit.benefitBalance.term
Definition

Условие или период действия, например 'максимальная льгота на протяжении жизни' или 'максимальное количество визитов в год'.

Control0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

ExplanationOfBenefit.benefitBalance.financial
Element IdExplanationOfBenefit.benefitBalance.financial
Definition

Льготы, используемые на сегодняшний день.

Control0..*
ExplanationOfBenefit.benefitBalance.financial.type
Element IdExplanationOfBenefit.benefitBalance.financial.type
Definition

Classification of benefit being provided.

Control1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the nature of the benefit.

Comments

For example: deductible, visits, benefit amount.

ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Element IdExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition

The quantity of the benefit which is permitted under the coverage.

Control0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to convey the benefits offered under the coverage.

ExplanationOfBenefit.benefitBalance.financial.used[x]
Element IdExplanationOfBenefit.benefitBalance.financial.used[x]
Definition

The quantity of the benefit which have been consumed to date.

Control0..1
TypeunsignedInt|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to convey the benefits consumed to date.