ExplanationOfBenefit

Trial Use 2 Financial

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

devhttps://api.sandbox.ovok.com/fhir/R5/ExplanationOfBenefit

Interaction	Method	Path
Read	GET	/fhir/R5/ExplanationOfBenefit/[id]
Vread	GET	/fhir/R5/ExplanationOfBenefit/[id]/_history/[vid]
Update	PUT	/fhir/R5/ExplanationOfBenefit/[id]
Patch	PATCH	/fhir/R5/ExplanationOfBenefit/[id]
Delete	DELETE	/fhir/R5/ExplanationOfBenefit/[id]
Create	POST	/fhir/R5/ExplanationOfBenefit
Search	GET	/fhir/R5/ExplanationOfBenefit?...
History	GET	/fhir/R5/ExplanationOfBenefit/[id]/_history
Type-history	GET	/fhir/R5/ExplanationOfBenefit/_history

Top-level elements

Element	Type(s)	Cardinality	Description
identifier	Identifier	0..*	Business Identifier for the resource
traceNumber	Identifier	0..*	Number for tracking
status	code	1..1	active
type	CodeableConcept	1..1	Category or discipline
subType	CodeableConcept	0..1	More granular claim type
use	code	1..1	claim
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	0..1	Party responsible for reimbursement
provider	Reference	0..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originalPrescription	Reference	0..1	Original prescription if superceded by fulfiller
event	BackboneElement	0..*	Event information
payee	BackboneElement	0..1	Recipient of benefits payable
referral	Reference	0..1	Treatment Referral
encounter	Reference	0..*	Encounters associated with the listed treatments
facility	Reference	0..1	Servicing Facility
claim	Reference	0..1	Claim reference
claimResponse	Reference	0..1	Claim response reference
outcome	code	1..1	queued
decision	CodeableConcept	0..1	Result of the adjudication
disposition	string	0..1	Disposition Message
preAuthRef	string	0..*	Preauthorization reference
preAuthRefPeriod	Period	0..*	Preauthorization in-effect period
diagnosisRelatedGroup	CodeableConcept	0..1	Package billing code
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	0..*	Patient insurance information
accident	BackboneElement	0..1	Details of the event
patientPaid	Money	0..1	Paid by the patient
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

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	Encounter related to the activity recorded in the AuditEvent
enterer	reference	The party responsible for the entry of the Claim
facility	reference	Facility responsible for the goods and services
identifier	token	Account number
item-udi	reference	UDI associated with a line item product or service
patient	reference	The entity that caused the expenses
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 R5 spec: ExplanationOfBenefit
• Maturity: Trial Use 2 (FMM 2).