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.
These interaction paths describe standard FHIR R4 patterns. Availability can depend on the API capabilities enabled for your Ovok project.
| 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 | Cardinality | Description |
|---|---|---|---|
id | string | 0..1 | Logical id of this artifact |
meta | Meta | 0..1 | Metadata about the resource |
implicitRules | uri | 0..1 | A set of rules under which this content was created |
language | code | 0..1 | Language of the resource content |
text | Narrative | 0..1 | Text summary of the resource, for human interpretation |
contained | Resource | 0..* | Contained, inline Resources |
extension | Extension | 0..* | Additional content defined by implementations |
modifierExtension | Extension | 0..* | Extensions that cannot be ignored |
identifier | Identifier | 0..* | Business Identifier for the resource |
status | code | 1..1 | active | cancelled | draft | entered-in-error |
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 | BackboneElement | 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
| Parameter | Type | Description |
|---|---|---|
care-team | reference | Member of the CareTeam |
claim | reference | The reference to the claim |
coverage | reference | The plan under which the claim was adjudicated |
created | date | The creation date for the EOB |
detail-udi | reference | UDI associated with a line item detail product or service |
disposition | string | The contents of the disposition message |
encounter | reference | Encounters associated with a billed line item |
enterer | reference | The party responsible for the entry of the Claim |
facility | reference | Facility responsible for the goods and services |
identifier | token | The business identifier of the Explanation of Benefit |
item-udi | reference | UDI associated with a line item product or service |
patient | reference | The reference to the patient |
payee | reference | The party receiving any payment for the Claim |
procedure-udi | reference | UDI associated with a procedure |
provider | reference | The reference to the provider |
status | token | Status of the instance |
subdetail-udi | reference | UDI associated with a line item detail subdetail product or service |
Reference
Official FHIR R4 spec: ExplanationOfBenefit.
Maturity: Trial Use 2 (FMM 2).