description: 'This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.'
package_name: hl7.fhir.r4b.examples
derivation: specialization
name: ExplanationOfBenefit
type: ExplanationOfBenefit
elements:
  patient:
    isModifier: false
    short: The recipient of the products and services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 5
  claimResponse:
    isModifier: false
    short: Claim response reference
    refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 26
  insurance:
    min: 1
    isModifier: false
    short: Patient insurance information
    index: 72
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      focal: {isModifier: false, short: Coverage to be used for adjudication, type: boolean, mustSupport: false, isSummary: true, index: 73}
      coverage:
        isModifier: false
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        mustSupport: false
        isSummary: true
        index: 74
      preAuthRef: {isModifier: false, short: Prior authorization reference number, type: string, mustSupport: false, array: true, isSummary: false, index: 75}
    required: [coverage, focal]
    isSummary: true
  benefitBalance:
    isModifier: false
    short: Balance by Benefit Category
    index: 207
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      category:
        isModifier: false
        short: Benefit classification
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 208
      excluded: {isModifier: false, short: Excluded from the plan, type: boolean, mustSupport: false, isSummary: false, index: 209}
      name: {isModifier: false, short: Short name for the benefit, type: string, mustSupport: false, isSummary: false, index: 210}
      description: {isModifier: false, short: Description of the benefit or services covered, type: string, mustSupport: false, isSummary: false, index: 211}
      network:
        isModifier: false
        short: In or out of network
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-network'}
        isSummary: false
        index: 212
      unit:
        isModifier: false
        short: Individual or family
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        isSummary: false
        index: 213
      term:
        isModifier: false
        short: Annual or lifetime
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        isSummary: false
        index: 214
      financial:
        isModifier: false
        short: Benefit Summary
        index: 215
        type: BackboneElement
        mustSupport: false
        array: true
        elements:
          type:
            isModifier: false
            short: Benefit classification
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-type'}
            isSummary: false
            index: 216
          allowed:
            isModifier: false
            short: Benefits allowed
            mustSupport: false
            choices: [allowedUnsignedInt, allowedString, allowedMoney]
            isSummary: false
            index: 218
          allowedUnsignedInt: {isModifier: false, short: Benefits allowed, type: unsignedInt, mustSupport: false, choiceOf: allowed, isSummary: false, index: 219}
          allowedString: {isModifier: false, short: Benefits allowed, type: string, mustSupport: false, choiceOf: allowed, isSummary: false, index: 220}
          allowedMoney: {isModifier: false, short: Benefits allowed, type: Money, mustSupport: false, choiceOf: allowed, isSummary: false, index: 221}
          used:
            isModifier: false
            short: Benefits used
            mustSupport: false
            choices: [usedUnsignedInt, usedMoney]
            isSummary: false
            index: 223
          usedUnsignedInt: {isModifier: false, short: Benefits used, type: unsignedInt, mustSupport: false, choiceOf: used, isSummary: false, index: 224}
          usedMoney: {isModifier: false, short: Benefits used, type: Money, mustSupport: false, choiceOf: used, isSummary: false, index: 225}
        required: [type]
        isSummary: false
    required: [category]
    isSummary: false
  facility:
    isModifier: false
    short: Servicing Facility
    refers: ['http://hl7.org/fhir/StructureDefinition/Location']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 24
  processNote:
    isModifier: false
    short: Note concerning adjudication
    type: BackboneElement
    mustSupport: false
    array: true
    isSummary: false
    index: 201
    elements:
      number: {isModifier: false, short: Note instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 202}
      type:
        isModifier: false
        short: display | print | printoper
        type: code
        mustSupport: false
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type|4.3.0-snapshot1'}
        isSummary: false
        index: 203
      text: {isModifier: false, short: Note explanatory text, type: string, mustSupport: false, isSummary: false, index: 204}
      language:
        isModifier: false
        short: Language of the text
        type: CodeableConcept
        mustSupport: false
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'}
        isSummary: false
        index: 205
  diagnosis:
    isModifier: false
    short: Pertinent diagnosis information
    index: 53
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      sequence: {isModifier: false, short: Diagnosis instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 54}
      diagnosis:
        isModifier: false
        short: Nature of illness or problem
        mustSupport: false
        choices: [diagnosisCodeableConcept, diagnosisReference]
        isSummary: false
        index: 56
      diagnosisCodeableConcept: {isModifier: false, short: Nature of illness or problem, type: CodeableConcept, mustSupport: false, choiceOf: diagnosis, isSummary: false, index: 57}
      diagnosisReference:
        isModifier: false
        short: Nature of illness or problem
        index: 58
        refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
        type: Reference
        mustSupport: false
        choiceOf: diagnosis
        isSummary: false
      type:
        isModifier: false
        short: Timing or nature of the diagnosis
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        isSummary: false
        index: 59
      onAdmission:
        isModifier: false
        short: Present on admission
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        isSummary: false
        index: 60
      packageCode:
        isModifier: false
        short: Package billing code
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
        isSummary: false
        index: 61
    required: [diagnosisReference, diagnosis, diagnosisCodeableConcept, sequence]
    isSummary: false
  preAuthRef: {isModifier: false, short: Preauthorization reference, type: string, mustSupport: false, array: true, isSummary: false, index: 29}
  adjudication:
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
    isModifier: false
    short: Header-level adjudication
    mustSupport: false
    array: true
    isSummary: false
    index: 188
  enterer:
    isModifier: false
    short: Author of the claim
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 8
  supportingInfo:
    isModifier: false
    short: Supporting information
    index: 37
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      category:
        isModifier: false
        short: Classification of the supplied information
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        isSummary: false
        index: 39
      valueReference:
        isModifier: false
        short: Data to be provided
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        mustSupport: false
        choiceOf: value
        isSummary: false
        index: 51
      valueQuantity: {isModifier: false, short: Data to be provided, type: Quantity, mustSupport: false, choiceOf: value, isSummary: false, index: 49}
      timingPeriod: {isModifier: false, short: When it occurred, type: Period, mustSupport: false, choiceOf: timing, isSummary: false, index: 44}
      value:
        isModifier: false
        short: Data to be provided
        mustSupport: false
        choices: [valueBoolean, valueString, valueQuantity, valueAttachment, valueReference]
        isSummary: false
        index: 46
      valueString: {isModifier: false, short: Data to be provided, type: string, mustSupport: false, choiceOf: value, isSummary: false, index: 48}
      valueBoolean: {isModifier: false, short: Data to be provided, type: boolean, mustSupport: false, choiceOf: value, isSummary: false, index: 47}
      reason:
        isModifier: false
        short: Explanation for the information
        type: Coding
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        isSummary: false
        index: 52
      timing:
        isModifier: false
        short: When it occurred
        mustSupport: false
        choices: [timingDate, timingPeriod]
        isSummary: false
        index: 42
      sequence: {isModifier: false, short: Information instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 38}
      code:
        isModifier: false
        short: Type of information
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        isSummary: false
        index: 40
      timingDate: {isModifier: false, short: When it occurred, type: date, mustSupport: false, choiceOf: timing, isSummary: false, index: 43}
      valueAttachment: {isModifier: false, short: Data to be provided, type: Attachment, mustSupport: false, choiceOf: value, isSummary: false, index: 50}
    required: [sequence, category]
    isSummary: false
  use:
    isModifier: false
    short: claim | preauthorization | predetermination
    type: code
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.3.0-snapshot1'}
    isSummary: true
    index: 4
  payment:
    isModifier: false
    short: Payment Details
    type: BackboneElement
    mustSupport: false
    isSummary: false
    index: 192
    elements:
      type:
        isModifier: false
        short: Partial or complete payment
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        isSummary: false
        index: 193
      adjustment: {isModifier: false, short: Payment adjustment for non-claim issues, type: Money, mustSupport: false, isSummary: false, index: 194}
      adjustmentReason:
        isModifier: false
        short: Explanation for the variance
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        isSummary: false
        index: 195
      date: {isModifier: false, short: Expected date of payment, type: date, mustSupport: false, isSummary: false, index: 196}
      amount: {isModifier: false, short: Payable amount after adjustment, type: Money, mustSupport: false, isSummary: false, index: 197}
      identifier: {isModifier: false, short: Business identifier for the payment, type: Identifier, mustSupport: false, isSummary: false, index: 198}
  item:
    isModifier: false
    short: Product or service provided
    index: 83
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      category:
        isModifier: false
        short: Benefit classification
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 90
      diagnosisSequence: {isModifier: false, short: Applicable diagnoses, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 86}
      procedureSequence: {isModifier: false, short: Applicable procedures, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 87}
      locationAddress: {isModifier: false, short: Place of service or where product was supplied, type: Address, mustSupport: false, choiceOf: location, isSummary: false, index: 101}
      modifier:
        isModifier: false
        short: Product or service billing modifiers
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 92
      revenue:
        isModifier: false
        short: Revenue or cost center code
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        isSummary: false
        index: 89
      adjudication:
        isModifier: false
        short: Adjudication details
        index: 112
        type: BackboneElement
        mustSupport: false
        array: true
        elements:
          category:
            isModifier: false
            short: Type of adjudication information
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            isSummary: false
            index: 113
          reason:
            isModifier: false
            short: Explanation of adjudication outcome
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            isSummary: false
            index: 114
          amount: {isModifier: false, short: Monetary amount, type: Money, mustSupport: false, isSummary: false, index: 115}
          value: {isModifier: false, short: Non-monitary value, type: decimal, mustSupport: false, isSummary: false, index: 116}
        required: [category]
        isSummary: false
      encounter:
        isModifier: false
        short: Encounters related to this billed item
        refers: ['http://hl7.org/fhir/StructureDefinition/Encounter']
        type: Reference
        mustSupport: false
        array: true
        isSummary: false
        index: 110
      locationCodeableConcept: {isModifier: false, short: Place of service or where product was supplied, type: CodeableConcept, mustSupport: false, choiceOf: location, isSummary: false, index: 100}
      net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 106}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: [servicedDate, servicedPeriod]
        isSummary: false
        index: 95
      subSite:
        isModifier: false
        short: Anatomical sub-location
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        isSummary: false
        index: 109
      careTeamSequence: {isModifier: false, short: Applicable care team members, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 85}
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 91
      locationReference:
        isModifier: false
        short: Place of service or where product was supplied
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        mustSupport: false
        choiceOf: location
        isSummary: false
        index: 102
      udi:
        isModifier: false
        short: Unique device identifier
        refers: ['http://hl7.org/fhir/StructureDefinition/Device']
        type: Reference
        mustSupport: false
        array: true
        isSummary: false
        index: 107
      informationSequence: {isModifier: false, short: Applicable exception and supporting information, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 88}
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 93
      factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 105}
      servicedDate: {isModifier: false, short: Date or dates of service or product delivery, type: date, mustSupport: false, choiceOf: serviced, isSummary: false, index: 96}
      sequence: {isModifier: false, short: Item instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 84}
      bodySite:
        isModifier: false
        short: Anatomical location
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        isSummary: false
        index: 108
      quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 103}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: [locationCodeableConcept, locationAddress, locationReference]
        isSummary: false
        index: 99
      noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 111}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 104}
      servicedPeriod: {isModifier: false, short: Date or dates of service or product delivery, type: Period, mustSupport: false, choiceOf: serviced, isSummary: false, index: 97}
      detail:
        isModifier: false
        short: Additional items
        index: 117
        type: BackboneElement
        mustSupport: false
        array: true
        elements:
          category:
            isModifier: false
            short: Benefit classification
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            isSummary: false
            index: 120
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            type: CodeableConcept
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 122
          revenue:
            isModifier: false
            short: Revenue or cost center code
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            isSummary: false
            index: 119
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            isModifier: false
            short: Detail level adjudication details
            mustSupport: false
            array: true
            isSummary: false
            index: 130
          net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 127}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 121
          udi:
            isModifier: false
            short: Unique device identifier
            refers: ['http://hl7.org/fhir/StructureDefinition/Device']
            type: Reference
            mustSupport: false
            array: true
            isSummary: false
            index: 128
          programCode:
            isModifier: false
            short: Program the product or service is provided under
            type: CodeableConcept
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            isSummary: false
            index: 123
          factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 126}
          sequence: {isModifier: false, short: Product or service provided, type: positiveInt, mustSupport: false, isSummary: false, index: 118}
          subDetail:
            isModifier: false
            short: Additional items
            index: 131
            type: BackboneElement
            mustSupport: false
            array: true
            elements:
              category:
                isModifier: false
                short: Benefit classification
                type: CodeableConcept
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                isSummary: false
                index: 134
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                type: CodeableConcept
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 136
              revenue:
                isModifier: false
                short: Revenue or cost center code
                type: CodeableConcept
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                isSummary: false
                index: 133
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                isModifier: false
                short: Subdetail level adjudication details
                mustSupport: false
                array: true
                isSummary: false
                index: 144
              net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 141}
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                type: CodeableConcept
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 135
              udi:
                isModifier: false
                short: Unique device identifier
                refers: ['http://hl7.org/fhir/StructureDefinition/Device']
                type: Reference
                mustSupport: false
                array: true
                isSummary: false
                index: 142
              programCode:
                isModifier: false
                short: Program the product or service is provided under
                type: CodeableConcept
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                isSummary: false
                index: 137
              factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 140}
              sequence: {isModifier: false, short: Product or service provided, type: positiveInt, mustSupport: false, isSummary: false, index: 132}
              quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 138}
              noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 143}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 139}
            required: [sequence, productOrService]
            isSummary: false
          quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 124}
          noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 129}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 125}
        required: [sequence, productOrService]
        isSummary: false
    required: [sequence, productOrService]
    isSummary: false
  type:
    isModifier: false
    short: Category or discipline
    type: CodeableConcept
    mustSupport: false
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {isModifier: false, short: Response creation date, type: dateTime, mustSupport: false, isSummary: true, index: 7}
  procedure:
    isModifier: false
    short: Clinical procedures performed
    index: 62
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      sequence: {isModifier: false, short: Procedure instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 63}
      type:
        isModifier: false
        short: Category of Procedure
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        isSummary: false
        index: 64
      date: {isModifier: false, short: When the procedure was performed, type: dateTime, mustSupport: false, isSummary: false, index: 65}
      procedure:
        isModifier: false
        short: Specific clinical procedure
        mustSupport: false
        choices: [procedureCodeableConcept, procedureReference]
        isSummary: false
        index: 67
      procedureCodeableConcept: {isModifier: false, short: Specific clinical procedure, type: CodeableConcept, mustSupport: false, choiceOf: procedure, isSummary: false, index: 68}
      procedureReference:
        isModifier: false
        short: Specific clinical procedure
        index: 69
        refers: ['http://hl7.org/fhir/StructureDefinition/Procedure']
        type: Reference
        mustSupport: false
        choiceOf: procedure
        isSummary: false
      udi:
        isModifier: false
        short: Unique device identifier
        refers: ['http://hl7.org/fhir/StructureDefinition/Device']
        type: Reference
        mustSupport: false
        array: true
        isSummary: false
        index: 70
    required: [procedureReference, sequence, procedure, procedureCodeableConcept]
    isSummary: false
  outcome:
    isModifier: false
    short: queued | complete | error | partial
    type: code
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0-snapshot1'}
    isSummary: true
    index: 27
  related:
    isModifier: false
    short: Prior or corollary claims
    type: BackboneElement
    mustSupport: false
    array: true
    isSummary: false
    index: 14
    elements:
      claim:
        isModifier: false
        short: Reference to the related claim
        refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 15
      relationship:
        isModifier: false
        short: How the reference claim is related
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        isSummary: false
        index: 16
      reference: {isModifier: false, short: File or case reference, type: Identifier, mustSupport: false, isSummary: false, index: 17}
  disposition: {isModifier: false, short: Disposition Message, type: string, mustSupport: false, isSummary: false, index: 28}
  referral:
    isModifier: false
    short: Treatment Referral
    refers: ['http://hl7.org/fhir/StructureDefinition/ServiceRequest']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 23
  preAuthRefPeriod: {isModifier: false, short: Preauthorization in-effect period, type: Period, mustSupport: false, array: true, isSummary: false, index: 30}
  total:
    isModifier: false
    short: Adjudication totals
    index: 189
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      category:
        isModifier: false
        short: Type of adjudication information
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 190
      amount: {isModifier: false, short: Financial total for the category, type: Money, mustSupport: false, isSummary: true, index: 191}
    required: [amount, category]
    isSummary: true
  insurer:
    isModifier: false
    short: Party responsible for reimbursement
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 9
  fundsReserve:
    isModifier: false
    short: Funds reserved status
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 13
  priority:
    isModifier: false
    short: Desired processing urgency
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://terminology.hl7.org/CodeSystem/processpriority'}
    isSummary: false
    index: 11
  accident:
    isModifier: false
    short: Details of the event
    type: BackboneElement
    mustSupport: false
    isSummary: false
    index: 76
    elements:
      date: {isModifier: false, short: When the incident occurred, type: date, mustSupport: false, isSummary: false, index: 77}
      type:
        isModifier: false
        short: The nature of the accident
        type: CodeableConcept
        mustSupport: false
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        isSummary: false
        index: 78
      location:
        isModifier: false
        short: Where the event occurred
        mustSupport: false
        choices: [locationAddress, locationReference]
        isSummary: false
        index: 80
      locationAddress: {isModifier: false, short: Where the event occurred, type: Address, mustSupport: false, choiceOf: location, isSummary: false, index: 81}
      locationReference:
        isModifier: false
        short: Where the event occurred
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        mustSupport: false
        choiceOf: location
        isSummary: false
        index: 82
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    index: 1
    type: code
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.3.0-snapshot1'}
    isModifierReason: 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
    isSummary: true
  payee:
    isModifier: false
    short: Recipient of benefits payable
    type: BackboneElement
    mustSupport: false
    isSummary: false
    index: 20
    elements:
      type:
        isModifier: false
        short: Category of recipient
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        isSummary: false
        index: 21
      party:
        isModifier: false
        short: Recipient reference
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Patient', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 22
  prescription:
    isModifier: false
    short: Prescription authorizing services or products
    refers: ['http://hl7.org/fhir/StructureDefinition/MedicationRequest', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 18
  billablePeriod: {isModifier: false, short: Relevant time frame for the claim, type: Period, mustSupport: false, isSummary: true, index: 6}
  identifier: {isModifier: false, short: Business Identifier for the resource, type: Identifier, mustSupport: false, array: true, isSummary: false, index: 0}
  form: {isModifier: false, short: Printed reference or actual form, type: Attachment, mustSupport: false, isSummary: false, index: 200}
  subType:
    isModifier: false
    short: More granular claim type
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    isSummary: false
    index: 3
  fundsReserveRequested:
    isModifier: false
    short: For whom to reserve funds
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 12
  benefitPeriod: {isModifier: false, short: When the benefits are applicable, type: Period, mustSupport: false, isSummary: false, index: 206}
  precedence: {isModifier: false, short: 'Precedence (primary, secondary, etc.)', type: positiveInt, mustSupport: false, isSummary: false, index: 71}
  formCode:
    isModifier: false
    short: Printed form identifier
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    isSummary: false
    index: 199
  provider:
    isModifier: false
    short: Party responsible for the claim
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 10
  addItem:
    isModifier: false
    short: Insurer added line items
    index: 145
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      locationAddress: {isModifier: false, short: Place of service or where product was supplied, type: Address, mustSupport: false, choiceOf: location, isSummary: false, index: 160}
      modifier:
        isModifier: false
        short: Service/Product billing modifiers
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 151
      adjudication:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
        isModifier: false
        short: Added items adjudication
        mustSupport: false
        array: true
        isSummary: false
        index: 169
      locationCodeableConcept: {isModifier: false, short: Place of service or where product was supplied, type: CodeableConcept, mustSupport: false, choiceOf: location, isSummary: false, index: 159}
      itemSequence: {isModifier: false, short: Item sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 146}
      net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 165}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: [servicedDate, servicedPeriod]
        isSummary: false
        index: 154
      detailSequence: {isModifier: false, short: Detail sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 147}
      subSite:
        isModifier: false
        short: Anatomical sub-location
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        isSummary: false
        index: 167
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 150
      locationReference:
        isModifier: false
        short: Place of service or where product was supplied
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        mustSupport: false
        choiceOf: location
        isSummary: false
        index: 161
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 152
      factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 164}
      servicedDate: {isModifier: false, short: Date or dates of service or product delivery, type: date, mustSupport: false, choiceOf: serviced, isSummary: false, index: 155}
      subDetailSequence: {isModifier: false, short: Subdetail sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 148}
      bodySite:
        isModifier: false
        short: Anatomical location
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        isSummary: false
        index: 166
      quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 162}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: [locationCodeableConcept, locationAddress, locationReference]
        isSummary: false
        index: 158
      provider:
        isModifier: false
        short: Authorized providers
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        mustSupport: false
        array: true
        isSummary: false
        index: 149
      noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 168}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 163}
      servicedPeriod: {isModifier: false, short: Date or dates of service or product delivery, type: Period, mustSupport: false, choiceOf: serviced, isSummary: false, index: 156}
      detail:
        isModifier: false
        short: Insurer added line items
        index: 170
        type: BackboneElement
        mustSupport: false
        array: true
        elements:
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            type: CodeableConcept
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 172
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
            isModifier: false
            short: Added items adjudication
            mustSupport: false
            array: true
            isSummary: false
            index: 178
          net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 176}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            type: CodeableConcept
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 171
          factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 175}
          subDetail:
            isModifier: false
            short: Insurer added line items
            index: 179
            type: BackboneElement
            mustSupport: false
            array: true
            elements:
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                type: CodeableConcept
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 180
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                type: CodeableConcept
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 181
              quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 182}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 183}
              factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 184}
              net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 185}
              noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 186}
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit', elements, item, elements, adjudication]
                isModifier: false
                short: Added items adjudication
                mustSupport: false
                array: true
                isSummary: false
                index: 187
            required: [productOrService]
            isSummary: false
          quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 173}
          noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 177}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 174}
        required: [productOrService]
        isSummary: false
    required: [productOrService]
    isSummary: false
  originalPrescription:
    isModifier: false
    short: Original prescription if superceded by fulfiller
    refers: ['http://hl7.org/fhir/StructureDefinition/MedicationRequest']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 19
  careTeam:
    isModifier: false
    short: Care Team members
    index: 31
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      sequence: {isModifier: false, short: Order of care team, type: positiveInt, mustSupport: false, isSummary: false, index: 32}
      provider:
        isModifier: false
        short: Practitioner or organization
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 33
      responsible: {isModifier: false, short: Indicator of the lead practitioner, type: boolean, mustSupport: false, isSummary: false, index: 34}
      role:
        isModifier: false
        short: Function within the team
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        isSummary: false
        index: 35
      qualification:
        isModifier: false
        short: Practitioner credential or specialization
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        isSummary: false
        index: 36
    required: [provider, sequence]
    isSummary: false
  claim:
    isModifier: false
    short: Claim reference
    refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 25
package_version: 4.3.0-snapshot1
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.3.0-snapshot1
required: [created, insurer, provider, status, insurance, type, patient, use, outcome]