ExplanationOfBenefit
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.
Endpoints
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https://api.dev.ovok.com/fhir/R4/ExplanationOfBenefit| Interaction | Method | Path |
|---|---|---|
| Read | GET | /fhir/R4/ExplanationOfBenefit/[id] |
| Vread | GET | /fhir/R4/ExplanationOfBenefit/[id]/_history/[vid] |
| Update | PUT | /fhir/R4/ExplanationOfBenefit/[id] |
| Patch | PATCH | /fhir/R4/ExplanationOfBenefit/[id] |
| Delete | DELETE | /fhir/R4/ExplanationOfBenefit/[id] |
| Create | POST | /fhir/R4/ExplanationOfBenefit |
| Search | GET | /fhir/R4/ExplanationOfBenefit |
| History | GET | /fhir/R4/ExplanationOfBenefit/[id]/_history |
Top-level elements
| Element | Type(s) | Cardinality | Description |
|---|---|---|---|
identifier | Identifier | 0..* | Business Identifier for the resource |
status | code | 1..1 | active | cancelled | draft | entered-in-error modifier |
type | CodeableConcept | 1..1 | Category or discipline |
subType | CodeableConcept | 0..1 | More granular claim type |
use | code | 1..1 | claim | preauthorization | predetermination |
patient | Reference | 1..1 | The recipient of the products and services |
billablePeriod | Period | 0..1 | Relevant time frame for the claim |
created | dateTime | 1..1 | Response creation date |
enterer | Reference | 0..1 | Author of the claim |
insurer | Reference | 1..1 | Party responsible for reimbursement |
provider | Reference | 1..1 | Party responsible for the claim |
priority | CodeableConcept | 0..1 | Desired processing urgency |
fundsReserveRequested | CodeableConcept | 0..1 | For whom to reserve funds |
fundsReserve | CodeableConcept | 0..1 | Funds reserved status |
related | BackboneElement | 0..* | Prior or corollary claims |
prescription | Reference | 0..1 | Prescription authorizing services or products |
originalPrescription | Reference | 0..1 | Original prescription if superceded by fulfiller |
payee | BackboneElement | 0..1 | Recipient of benefits payable |
referral | Reference | 0..1 | Treatment Referral |
facility | Reference | 0..1 | Servicing Facility |
claim | Reference | 0..1 | Claim reference |
claimResponse | Reference | 0..1 | Claim response reference |
outcome | code | 1..1 | queued | complete | error | partial |
disposition | string | 0..1 | Disposition Message |
preAuthRef | string | 0..* | Preauthorization reference |
preAuthRefPeriod | Period | 0..* | Preauthorization in-effect period |
careTeam | BackboneElement | 0..* | Care Team members |
supportingInfo | BackboneElement | 0..* | Supporting information |
diagnosis | BackboneElement | 0..* | Pertinent diagnosis information |
procedure | BackboneElement | 0..* | Clinical procedures performed |
precedence | positiveInt | 0..1 | Precedence (primary, secondary, etc.) |
insurance | BackboneElement | 1..* | Patient insurance information |
accident | BackboneElement | 0..1 | Details of the event |
item | BackboneElement | 0..* | Product or service provided |
addItem | BackboneElement | 0..* | Insurer added line items |
adjudication | — | 0..* | Header-level adjudication |
total | BackboneElement | 0..* | Adjudication totals |
payment | BackboneElement | 0..1 | Payment Details |
formCode | CodeableConcept | 0..1 | Printed form identifier |
form | Attachment | 0..1 | Printed reference or actual form |
processNote | BackboneElement | 0..* | Note concerning adjudication |
benefitPeriod | Period | 0..1 | When the benefits are applicable |
benefitBalance | BackboneElement | 0..* | Balance by Benefit Category |
Resource-specific search parameters
Reference
- Official FHIR R4 spec:
ExplanationOfBenefit - Maturity: Trial Use 2 (FMM 2).