ExplanationOfBenefit (11)

#NameSourceVerDescription
1ADHA Medicare ExplanationOfBenefitau.digitalhealth.stu3.medicare-records#currentR3The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS), Department of Veterans’ Affairs (DVA), Pharmaceutical Benefits Schedule (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between Medicare repositories and the My Health Record system infrastructure in Australia.
2ADHA Record of Claim against MBS or DVAau.digitalhealth.r4#currentR4The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS) or Department of Veterans' Affairs (DVA) for the electronic exchange of digital health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.
3ADHA Record of Claim against PBS or RPBSau.digitalhealth.r4#currentR4The purpose of this profile is to define a representation of a record of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.
4C4BB Explanation Of Benefithl7.fhir.us.carin-bb#currentR4Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four concrete EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician
5C4BB ExplanationOfBenefit Inpatient Institutionalhl7.fhir.us.carin-bb#currentR4The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services.
6C4BB ExplanationOfBenefit Oralhl7.fhir.us.carin-bb#currentR4This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan.
7C4BB ExplanationOfBenefit Outpatient Institutionalhl7.fhir.us.carin-bb#currentR4This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services.
8C4BB ExplanationOfBenefit Pharmacyhl7.fhir.us.carin-bb#currentR4This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies. The claims data is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program)
9C4BB ExplanationOfBenefit Professional NonClinicianhl7.fhir.us.carin-bb#currentR4This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.
10PCT Advanced EOBhl7.fhir.us.davinci-pct#currentR4The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.
11PDex Prior Authorizationhl7.fhir.us.davinci-pdex#currentR4The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members
1 2 3 4 5 6 7 8 9 10 11
ExplanationOfBenefit I D D I I I I I I I
ExplanationOfBenefit.organization
ExplanationOfBenefit.meta C C
ExplanationOfBenefit.meta.lastUpdated C D
ExplanationOfBenefit.meta.profile C C D S C F (2)
ExplanationOfBenefit.implicitRules
ExplanationOfBenefit.language
ExplanationOfBenefit.text
ExplanationOfBenefit.contained
ExplanationOfBenefit.extension S C (4) S C (2)
ExplanationOfBenefit.modifierExtension
ExplanationOfBenefit.identifier C C C S C D (2) S C (3)
ExplanationOfBenefit.identifier.value C
ExplanationOfBenefit.identifier.type C F D (2) C F (2)
ExplanationOfBenefit.traceNumber
ExplanationOfBenefit.status F F F D
ExplanationOfBenefit.type B M F D B M F F F F B M B M
ExplanationOfBenefit.subType B M C B M C B M C F B M C F B M
ExplanationOfBenefit.use F F F D F F
ExplanationOfBenefit.patient C I I D
ExplanationOfBenefit.billablePeriod C
ExplanationOfBenefit.billablePeriod.end D
ExplanationOfBenefit.billablePeriod.start C D
ExplanationOfBenefit.created C I I D D
ExplanationOfBenefit.enterer
ExplanationOfBenefit.insurer I D I D D
ExplanationOfBenefit.provider D
ExplanationOfBenefit.priority B M B M B M B M B M
ExplanationOfBenefit.fundsReserveRequested
ExplanationOfBenefit.fundsReserve
ExplanationOfBenefit.related D
ExplanationOfBenefit.related.extension
ExplanationOfBenefit.related.modifierExtension
ExplanationOfBenefit.related.claim
ExplanationOfBenefit.related.relationship C B M
ExplanationOfBenefit.related.reference C
ExplanationOfBenefit.prescription C
ExplanationOfBenefit.prescription.reference C
ExplanationOfBenefit.originalPrescription
ExplanationOfBenefit.event
ExplanationOfBenefit.event.extension
ExplanationOfBenefit.event.modifierExtension
ExplanationOfBenefit.event.type
ExplanationOfBenefit.event.when[x]
ExplanationOfBenefit.payee I
ExplanationOfBenefit.payee.extension
ExplanationOfBenefit.payee.modifierExtension
ExplanationOfBenefit.payee.type C D B M
ExplanationOfBenefit.payee.party D
ExplanationOfBenefit.referral
ExplanationOfBenefit.encounter
ExplanationOfBenefit.facility
ExplanationOfBenefit.claim C
ExplanationOfBenefit.claim.identifier C D
ExplanationOfBenefit.claim.identifier.value C
ExplanationOfBenefit.claim.identifier.system
ExplanationOfBenefit.claimResponse
ExplanationOfBenefit.outcome F F D
ExplanationOfBenefit.decision
ExplanationOfBenefit.disposition
ExplanationOfBenefit.preAuthRef
ExplanationOfBenefit.preAuthRefPeriod C D
ExplanationOfBenefit.diagnosisRelatedGroup
ExplanationOfBenefit.careTeam I I I I I
ExplanationOfBenefit.careTeam.qualification B M B M B M
ExplanationOfBenefit.careTeam.extension
ExplanationOfBenefit.careTeam.modifierExtension
ExplanationOfBenefit.careTeam.sequence D
ExplanationOfBenefit.careTeam.provider D
ExplanationOfBenefit.careTeam.responsible
ExplanationOfBenefit.careTeam.role D C B M C B M C B M C B M C B M
ExplanationOfBenefit.careTeam.specialty
ExplanationOfBenefit.supportingInfo D S C D (10) S C D (9) S C D (8) S C D (9) S C D (12)
ExplanationOfBenefit.supportingInfo.extension
ExplanationOfBenefit.supportingInfo.modifierExtension
ExplanationOfBenefit.supportingInfo.sequence D
ExplanationOfBenefit.supportingInfo.category B M F (9) F (8) F (7) F (8) F (11)
ExplanationOfBenefit.supportingInfo.code C B M (5) C D B M (3) C B M (4) C B M (4) C (7)
ExplanationOfBenefit.supportingInfo.timing[x] S C (3) S C D (5) C C C (8)
ExplanationOfBenefit.supportingInfo.value[x] S C (4) S C D (8) S C (4) C (3) S C (12)
ExplanationOfBenefit.supportingInfo.value[x].system F (2)
ExplanationOfBenefit.supportingInfo.value[x].unit F (2)
ExplanationOfBenefit.supportingInfo.value[x].value C (2)
ExplanationOfBenefit.supportingInfo.reason C B M
ExplanationOfBenefit.diagnosis C D D C D C D
ExplanationOfBenefit.diagnosis.extension
ExplanationOfBenefit.diagnosis.modifierExtension
ExplanationOfBenefit.diagnosis.sequence D D D D
ExplanationOfBenefit.diagnosis.diagnosis[x] B M B M B M B M
ExplanationOfBenefit.diagnosis.type C D B M C D B M C D B M C D B M
ExplanationOfBenefit.diagnosis.onAdmission D B M
ExplanationOfBenefit.procedure D
ExplanationOfBenefit.procedure.extension
ExplanationOfBenefit.procedure.modifierExtension
ExplanationOfBenefit.procedure.sequence D
ExplanationOfBenefit.procedure.type C D B M
ExplanationOfBenefit.procedure.date
ExplanationOfBenefit.procedure.procedure[x] B M
ExplanationOfBenefit.procedure.udi
ExplanationOfBenefit.precedence
ExplanationOfBenefit.insurance C C I D
ExplanationOfBenefit.insurance.extension
ExplanationOfBenefit.insurance.modifierExtension
ExplanationOfBenefit.insurance.focal F F D
ExplanationOfBenefit.insurance.coverage D D D
ExplanationOfBenefit.insurance.preAuthRef
ExplanationOfBenefit.accident
ExplanationOfBenefit.accident.extension
ExplanationOfBenefit.accident.modifierExtension
ExplanationOfBenefit.accident.date
ExplanationOfBenefit.accident.type
ExplanationOfBenefit.accident.location[x]
ExplanationOfBenefit.patientPaid
ExplanationOfBenefit.item C C C C I I C
ExplanationOfBenefit.item.subSite D B M
ExplanationOfBenefit.item.service C B M
ExplanationOfBenefit.item.extension S C I (2) S C (8)
ExplanationOfBenefit.item.modifierExtension
ExplanationOfBenefit.item.sequence F F F D
ExplanationOfBenefit.item.careTeamSequence
ExplanationOfBenefit.item.diagnosisSequence
ExplanationOfBenefit.item.procedureSequence
ExplanationOfBenefit.item.informationSequence
ExplanationOfBenefit.item.traceNumber
ExplanationOfBenefit.item.revenue C D B M D B M B M
ExplanationOfBenefit.item.category B M C B M C B M B M
ExplanationOfBenefit.item.productOrService F D F D D B M D B M D B M D B M I D B M B M B M
ExplanationOfBenefit.item.productOrServiceEnd
ExplanationOfBenefit.item.request
ExplanationOfBenefit.item.modifier D B M D B M D B M D B M C B M
ExplanationOfBenefit.item.programCode
ExplanationOfBenefit.item.serviced[x] C C C C D C C D C D C D
ExplanationOfBenefit.item.location[x] F D C D B M C D B M
ExplanationOfBenefit.item.patientPaid
ExplanationOfBenefit.item.quantity D D D D D
ExplanationOfBenefit.item.unitPrice
ExplanationOfBenefit.item.factor
ExplanationOfBenefit.item.tax
ExplanationOfBenefit.item.net
ExplanationOfBenefit.item.udi
ExplanationOfBenefit.item.bodySite D B M
ExplanationOfBenefit.item.bodySite.extension
ExplanationOfBenefit.item.bodySite.modifierExtension
ExplanationOfBenefit.item.bodySite.site
ExplanationOfBenefit.item.bodySite.subSite
ExplanationOfBenefit.item.encounter
ExplanationOfBenefit.item.noteNumber D
ExplanationOfBenefit.item.reviewOutcome
ExplanationOfBenefit.item.reviewOutcome.extension
ExplanationOfBenefit.item.reviewOutcome.modifierExtension
ExplanationOfBenefit.item.reviewOutcome.decision
ExplanationOfBenefit.item.reviewOutcome.reason
ExplanationOfBenefit.item.reviewOutcome.preAuthRef
ExplanationOfBenefit.item.reviewOutcome.preAuthPeriod
ExplanationOfBenefit.item.adjudication S C D (4) S C D (5) S C D (4) S C D (3) S C D (5) S C D (8) S C (5)
ExplanationOfBenefit.item.adjudication.value C C C C (2)
ExplanationOfBenefit.item.adjudication.extension S C (2) S C (2)
ExplanationOfBenefit.item.adjudication.modifierExtension
ExplanationOfBenefit.item.adjudication.category F B M (4) F B M (5) F B M (4) F B M (3) F B M (5) F B M (8) F B M (5)
ExplanationOfBenefit.item.adjudication.reason C B M C B M (2) C B M C B M C B M (2) B M (2) C B M
ExplanationOfBenefit.item.adjudication.amount C C C C C C C
ExplanationOfBenefit.item.adjudication.quantity
ExplanationOfBenefit.item.detail
ExplanationOfBenefit.item.detail.extension
ExplanationOfBenefit.item.detail.modifierExtension
ExplanationOfBenefit.item.detail.sequence
ExplanationOfBenefit.item.detail.traceNumber
ExplanationOfBenefit.item.detail.revenue
ExplanationOfBenefit.item.detail.category
ExplanationOfBenefit.item.detail.productOrService D B M
ExplanationOfBenefit.item.detail.productOrServiceEnd
ExplanationOfBenefit.item.detail.modifier
ExplanationOfBenefit.item.detail.programCode
ExplanationOfBenefit.item.detail.patientPaid
ExplanationOfBenefit.item.detail.quantity
ExplanationOfBenefit.item.detail.unitPrice
ExplanationOfBenefit.item.detail.factor
ExplanationOfBenefit.item.detail.tax
ExplanationOfBenefit.item.detail.net
ExplanationOfBenefit.item.detail.udi
ExplanationOfBenefit.item.detail.noteNumber
ExplanationOfBenefit.item.detail.reviewOutcome
ExplanationOfBenefit.item.detail.adjudication
ExplanationOfBenefit.item.detail.subDetail
ExplanationOfBenefit.item.detail.subDetail.extension
ExplanationOfBenefit.item.detail.subDetail.modifierExtension
ExplanationOfBenefit.item.detail.subDetail.sequence
ExplanationOfBenefit.item.detail.subDetail.traceNumber
ExplanationOfBenefit.item.detail.subDetail.revenue
ExplanationOfBenefit.item.detail.subDetail.category
ExplanationOfBenefit.item.detail.subDetail.productOrService
ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd
ExplanationOfBenefit.item.detail.subDetail.modifier
ExplanationOfBenefit.item.detail.subDetail.programCode
ExplanationOfBenefit.item.detail.subDetail.patientPaid
ExplanationOfBenefit.item.detail.subDetail.quantity
ExplanationOfBenefit.item.detail.subDetail.unitPrice
ExplanationOfBenefit.item.detail.subDetail.factor
ExplanationOfBenefit.item.detail.subDetail.tax
ExplanationOfBenefit.item.detail.subDetail.net
ExplanationOfBenefit.item.detail.subDetail.udi
ExplanationOfBenefit.item.detail.subDetail.noteNumber
ExplanationOfBenefit.item.detail.subDetail.reviewOutcome
ExplanationOfBenefit.item.detail.subDetail.adjudication
ExplanationOfBenefit.addItem
ExplanationOfBenefit.addItem.extension
ExplanationOfBenefit.addItem.modifierExtension
ExplanationOfBenefit.addItem.itemSequence
ExplanationOfBenefit.addItem.detailSequence
ExplanationOfBenefit.addItem.subDetailSequence
ExplanationOfBenefit.addItem.traceNumber
ExplanationOfBenefit.addItem.provider
ExplanationOfBenefit.addItem.revenue
ExplanationOfBenefit.addItem.productOrService
ExplanationOfBenefit.addItem.productOrServiceEnd
ExplanationOfBenefit.addItem.request
ExplanationOfBenefit.addItem.modifier
ExplanationOfBenefit.addItem.programCode
ExplanationOfBenefit.addItem.serviced[x]
ExplanationOfBenefit.addItem.location[x]
ExplanationOfBenefit.addItem.patientPaid
ExplanationOfBenefit.addItem.quantity
ExplanationOfBenefit.addItem.unitPrice
ExplanationOfBenefit.addItem.factor
ExplanationOfBenefit.addItem.tax
ExplanationOfBenefit.addItem.net
ExplanationOfBenefit.addItem.bodySite
ExplanationOfBenefit.addItem.bodySite.extension
ExplanationOfBenefit.addItem.bodySite.modifierExtension
ExplanationOfBenefit.addItem.bodySite.site
ExplanationOfBenefit.addItem.bodySite.subSite
ExplanationOfBenefit.addItem.noteNumber
ExplanationOfBenefit.addItem.reviewOutcome
ExplanationOfBenefit.addItem.adjudication
ExplanationOfBenefit.addItem.detail
ExplanationOfBenefit.addItem.detail.extension
ExplanationOfBenefit.addItem.detail.modifierExtension
ExplanationOfBenefit.addItem.detail.traceNumber
ExplanationOfBenefit.addItem.detail.revenue
ExplanationOfBenefit.addItem.detail.productOrService
ExplanationOfBenefit.addItem.detail.productOrServiceEnd
ExplanationOfBenefit.addItem.detail.modifier
ExplanationOfBenefit.addItem.detail.patientPaid
ExplanationOfBenefit.addItem.detail.quantity
ExplanationOfBenefit.addItem.detail.unitPrice
ExplanationOfBenefit.addItem.detail.factor
ExplanationOfBenefit.addItem.detail.tax
ExplanationOfBenefit.addItem.detail.net
ExplanationOfBenefit.addItem.detail.noteNumber
ExplanationOfBenefit.addItem.detail.reviewOutcome
ExplanationOfBenefit.addItem.detail.adjudication
ExplanationOfBenefit.addItem.detail.subDetail
ExplanationOfBenefit.addItem.detail.subDetail.extension
ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension
ExplanationOfBenefit.addItem.detail.subDetail.traceNumber
ExplanationOfBenefit.addItem.detail.subDetail.revenue
ExplanationOfBenefit.addItem.detail.subDetail.productOrService
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd
ExplanationOfBenefit.addItem.detail.subDetail.modifier
ExplanationOfBenefit.addItem.detail.subDetail.patientPaid
ExplanationOfBenefit.addItem.detail.subDetail.quantity
ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
ExplanationOfBenefit.addItem.detail.subDetail.factor
ExplanationOfBenefit.addItem.detail.subDetail.tax
ExplanationOfBenefit.addItem.detail.subDetail.net
ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome
ExplanationOfBenefit.addItem.detail.subDetail.adjudication
ExplanationOfBenefit.adjudication S C D (5) S C D (4) S C D (5) S C D (3) S C D (3) S C D (10) S C (3)
ExplanationOfBenefit.adjudication.value C
ExplanationOfBenefit.adjudication.extension S C (2) S C (2)
ExplanationOfBenefit.adjudication.amount C C C C
ExplanationOfBenefit.adjudication.reason C D B M (3) C B M (3) C D B M (3) C B M (2) C B M (2) B M (4)
ExplanationOfBenefit.adjudication.category F B M (5) F B M (4) F B M (5) F B M (3) F B M (3) F B M (10) B M (2)
ExplanationOfBenefit.total C S C D (2) S C D (2) S C D (2) S C D (2) S C D (2) S C (2)
ExplanationOfBenefit.total.extension S C (2)
ExplanationOfBenefit.total.modifierExtension
ExplanationOfBenefit.total.category B M (2) B M (2) B M (2) B M (2) B M (2) B M (2) B M
ExplanationOfBenefit.total.amount D (2) D D (2) D (2) D
ExplanationOfBenefit.payment
ExplanationOfBenefit.payment.extension
ExplanationOfBenefit.payment.modifierExtension
ExplanationOfBenefit.payment.type D B M
ExplanationOfBenefit.payment.adjustment
ExplanationOfBenefit.payment.adjustmentReason
ExplanationOfBenefit.payment.date D
ExplanationOfBenefit.payment.amount
ExplanationOfBenefit.payment.identifier
ExplanationOfBenefit.formCode
ExplanationOfBenefit.form
ExplanationOfBenefit.processNote C
ExplanationOfBenefit.processNote.extension S C (2)
ExplanationOfBenefit.processNote.modifierExtension
ExplanationOfBenefit.processNote.number
ExplanationOfBenefit.processNote.type
ExplanationOfBenefit.processNote.text D
ExplanationOfBenefit.processNote.language
ExplanationOfBenefit.benefitPeriod C
ExplanationOfBenefit.benefitBalance C
ExplanationOfBenefit.benefitBalance.extension
ExplanationOfBenefit.benefitBalance.modifierExtension
ExplanationOfBenefit.benefitBalance.category B M
ExplanationOfBenefit.benefitBalance.excluded
ExplanationOfBenefit.benefitBalance.name
ExplanationOfBenefit.benefitBalance.description
ExplanationOfBenefit.benefitBalance.network
ExplanationOfBenefit.benefitBalance.unit C B M
ExplanationOfBenefit.benefitBalance.term C B M
ExplanationOfBenefit.benefitBalance.financial C
ExplanationOfBenefit.benefitBalance.financial.usedMoney C
ExplanationOfBenefit.benefitBalance.financial.allowedMoney C
ExplanationOfBenefit.benefitBalance.financial.extension
ExplanationOfBenefit.benefitBalance.financial.modifierExtension
ExplanationOfBenefit.benefitBalance.financial.type B M
ExplanationOfBenefit.benefitBalance.financial.allowed[x] S C
ExplanationOfBenefit.benefitBalance.financial.used[x] S C
S: There is slicing defined in the element(s)
C: There is cardinality erstrictions defined in the element(s)
I: There is invariants defined in the element(s)
F: There is a fixed or pattern value defined in the element(s)
D: There is document provided in the element(s)
B: There is terminology bindings defined in the element(s)
M: At least one of the element(s) has must-support = true
(N): The number of elements if > 1

Produced 08 Sep 2023