| Australian Digital Health Agency Medicare Records FHIR Implementation Guide 2.1.0

Australian Digital Health Agency Medicare Records FHIR Implementation Guide. The current version which supersedes this version is 2.2.0. It is based on FHIR® version 3.0.2. See the Directory of published versions for a list of available versions.

### StructureDefinition: ADHA Medicare ExplanationOfBenefit [Active]

The 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.

##### Usage scenarios

The following are the usage scenarios expected:

- An individual’s MBS claim item records are uploaded to the My Health Record system from a Medicare repository
- An individual’s PBS claim item records are uploaded to the My Health Record system from a Medicare repository

##### Each Explanation of Benefit SHALL have

1. a profile assertion to this profile
2. an identifier for this explanation of benefit record
3. a patient
4. a creation date
5. an identification of the Medicare benefit (subtype or item.category)
6. an item that was claimed
7. a date of supply or service

##### Must Support

In the context of this profile Must Support SHALL be interpreted as follows.

- The system SHALL be able to store and retrieve the following elements:
  - status
  - type
  - subtype
  - created
  - provider
  - referral
  - prescription
  - item
  - item.sequence
  - item.category
  - item.service
  - item.serviced
  - item.quantity
- The system SHALL be able to take the following elements into account when performing processing:
  - identifier
  - patient

##### Profile-specific implementation guidance

- The patient resource should be identified in the patient element with a logical reference, i.e. an Australian IHI
- PBS record:
  - An ExplanationOfBenefit for a PBS record will represent prescription data as a MedicationRequest, including date of prescribing, number of repeats, and quantity
  - Generic name of a PBS item can be represented by the supplied item service code
  - Date of supply of the item is represented by item.serviced[x]
- MBS record:
  - An ExplanationOfBenefit for an MBS record will represent the requester of the service as part of a ReferralRequest
  - Whether a service was provided in a hospital is indicated by the use and value of item.location
  - Date of service is represented by item.serviced[x]

#### Formal Views of Profile Content

The official URL for this profile is:

    http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare

The 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.

This profile builds on ExplanationOfBenefit.

This profile was published on 2023-04-14 04:15:22+0000 as a active by Australian Digital Health Agency.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

- Differential Table
- Snapshot Table
- All

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription. inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription. inv-dh-eob-03: One of subType or item.category SHALL be present. inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy'). inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
meta |  | 1..1 | Meta | Metadata about the resource
profile |  | 1..* | uri | Profiles this resource claims to conform to
identifier | S | 1..1 | Identifier | Business Identifier
status | S | 0..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active
type | S | 0..1 | CodeableConcept | Type or discipline
subType | S | 0..* | CodeableConcept | Finer grained claim type information Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
patient | S | 1..1 | Reference(AU Base Patient) | The subject of the Products and Services
created | S | 1..1 | dateTime | Creation date
insurer |  | 0..1 | Reference(AU Base Organisation) | Insurer responsible for the EOB
provider | S | 0..1 | Reference(AU Base Practitioner) | Responsible provider for the claim
organization |  | 0..1 | Reference(AU Base Organisation) | Responsible organization for the claim
referral | S | 0..1 | Reference(ADHA MBS DVA ReferralRequest) {c} | Treatment Referral
prescription | S | 0..1 | Reference(ADHA PBS MedicationRequest) {c} | Prescription authorizing services or products
item | S | 1..1 | BackboneElement | Goods and Services
sequence | S | 1..1 | positiveInt | Service instance Fixed Value: 1
category | S | 0..1 | CodeableConcept | Type of service or product Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
service | S | 1..1 | CodeableConcept | Billing Code Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
serviced[x] | S | 1..1 | date, Period | Date or dates of Service
quantity | S | 0..1 | SimpleQuantity | Count of Products or Services
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription. inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription. inv-dh-eob-03: One of subType or item.category SHALL be present. inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy'). inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
profile | Σ | 1..* | uri | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: Common Languages (extensible): A human language.
Additional Bindings | Purpose
All Languages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..1 | Identifier | Business Identifier
status | ?!S Σ | 0..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type | S | 0..1 | CodeableConcept | Type or discipline Binding: Example Claim Type Codes (required): The type or discipline-style of the claim
subType | S | 0..* | CodeableConcept | Finer grained claim type information Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
patient | S | 1..1 | Reference(AU Base Patient) | The subject of the Products and Services
billablePeriod |  | 0..1 | Period | Period for charge submission
created | S | 1..1 | dateTime | Creation date
enterer |  | 0..1 | Reference(Practitioner) | Author
insurer |  | 0..1 | Reference(AU Base Organisation) | Insurer responsible for the EOB
provider | S | 0..1 | Reference(AU Base Practitioner) | Responsible provider for the claim
organization |  | 0..1 | Reference(AU Base Organisation) | Responsible organization for the claim
referral | S | 0..1 | Reference(ADHA MBS DVA ReferralRequest) {c} | Treatment Referral
facility |  | 0..1 | Reference(Location) | Servicing Facility
claim |  | 0..1 | Reference(Claim) | Claim reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome |  | 0..1 | CodeableConcept | complete | error | partial Binding: Claim Processing Codes (example): The result of the claim processing
disposition |  | 0..1 | string | Disposition Message
related |  | 0..* | BackboneElement | Related Claims which may be revelant to processing this claim
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: Example Related Claim Relationship Codes (example): Relationship of this claim to a related Claim
reference |  | 0..1 | Identifier | Related file or case reference
prescription | S | 0..1 | Reference(ADHA PBS MedicationRequest) {c} | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Party to be paid any benefits payable
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 0..1 | CodeableConcept | Type of party: Subscriber, Provider, other Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
resourceType |  | 0..1 | CodeableConcept | organization | patient | practitioner | relatedperson Binding: PayeeResourceType (required): The type of payee Resource
party |  | 0..1 | Reference(Practitioner | Organization | Patient | RelatedPerson) | Party to receive the payable
information |  | 0..* | BackboneElement | Exceptions, special considerations, the condition, situation, prior or concurrent issues
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Information instance identifier
category |  | 1..1 | CodeableConcept | General class of information Binding: Claim Information Category Codes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: Exception Codes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Additional Data or supporting information
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Reason associated with the information Binding: Missing Tooth Reason Codes (example): Reason codes for the missing teeth
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Number to covey order of careteam
provider |  | 1..1 | Reference(Practitioner | Organization) | Member of the Care Team
responsible |  | 0..1 | boolean | Billing practitioner
role |  | 0..1 | CodeableConcept | Role on the team Binding: Claim Care Team Role Codes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Type, classification or Specialization Binding: Example Provider Qualification Codes (example): Provider professional qualifications
diagnosis |  | 0..* | BackboneElement | List of Diagnosis
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Number to covey order of diagnosis
diagnosis[x] |  | 1..1 |  | Patient's diagnosis Binding: ICD-10 Codes (example): ICD10 Diagnostic codes
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (example): The type of the diagnosis: admitting, principal, discharge
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (example): The DRG codes associated with the diagnosis
procedure |  | 0..* | BackboneElement | Procedures performed
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Procedure sequence for reference
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Patient's list of procedures performed Binding: ICD-10 Procedure Codes (example): ICD10 Procedure codes
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
insurance |  | 0..1 | BackboneElement | Insurance or medical plan
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
coverage |  | 0..1 | Reference(Coverage) | Insurance information
preAuthRef |  | 0..* | string | Pre-Authorization/Determination Reference
accident |  | 0..1 | BackboneElement | Details of an accident
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
date |  | 0..1 | date | When the accident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (required): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Accident Place
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
employmentImpacted |  | 0..1 | Period | Period unable to work
hospitalization |  | 0..1 | Period | Period in hospital
item | S | 1..1 | BackboneElement | Goods and Services
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence | S | 1..1 | positiveInt | Service instance Fixed Value: 1
careTeamLinkId |  | 0..* | positiveInt | Applicable careteam members
diagnosisLinkId |  | 0..* | positiveInt | Applicable diagnoses
procedureLinkId |  | 0..* | positiveInt | Applicable procedures
informationLinkId |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category | S | 0..1 | CodeableConcept | Type of service or product Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
service | S | 1..1 | CodeableConcept | Billing Code Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
serviced[x] | S | 1..1 |  | Date or dates of Service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service Binding: Example Service Place Codes (example): Place where the service is rendered
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
bodySite |  | 0..1 | CodeableConcept | Service Location Binding: Oral Site Codes (example): The code for the teeth, quadrant, sextant and arch
subSite |  | 0..* | CodeableConcept | Service Sub-location Binding: Surface Codes (example): The code for the tooth surface and surface combinations
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
category |  | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Binding: Adjudication Value Codes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of Adjudication outcome Binding: Adjudication Reason Codes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitory value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Service instance
type |  | 1..1 | CodeableConcept | Group or type of product or service Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
quantity |  | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total additional item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Service instance
type |  | 1..1 | CodeableConcept | Type of product or service Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
quantity |  | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Net additional item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Language if different from the resource
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequenceLinkId |  | 0..* | positiveInt | Service instances
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
fee |  | 0..1 | Money | Professional fee or Product charge
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Added items details
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
fee |  | 0..1 | Money | Professional fee or Product charge
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items detail adjudication
totalCost |  | 0..1 | Money | Total Cost of service from the Claim
unallocDeductable |  | 0..1 | Money | Unallocated deductable
totalBenefit |  | 0..1 | Money | Total benefit payable for the Claim
payment |  | 0..1 | BackboneElement | Payment (if paid)
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 0..1 | CodeableConcept | Partial or Complete Binding: Example Payment Type Codes (example): The type (partial, complete) of the payment
adjustment |  | 0..1 | Money | Payment adjustment for non-Claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Binding: Payment Adjustment Reason Codes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of Payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Identifier of the payment instrument
form |  | 0..1 | CodeableConcept | Printed Form Identifier Binding: Form Codes (example): The forms codes.
processNote |  | 0..* | BackboneElement | Processing notes
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
number |  | 0..1 | positiveInt | Sequence number for this note
type |  | 0..1 | CodeableConcept | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanitory text
language |  | 0..1 | CodeableConcept | Language if different from the resource Binding: Common Languages (extensible): A human language.
Additional Bindings | Purpose
All Languages | Max Binding
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
category |  | 1..1 | CodeableConcept | Type of services covered Binding: Benefit Category Codes (example): Benefit categories such as: oral, medical, vision etc.
subCategory |  | 0..1 | CodeableConcept | Detailed services covered within the type Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: Network Type Codes (example): Code to classify in or out of network services
unit |  | 0..1 | CodeableConcept | Individual or family Binding: Unit Type Codes (example): Unit covered/serviced - individual or family
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: Benefit Term Codes (example): Coverage unit - annual, lifetime
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 1..1 | CodeableConcept | Deductable, visits, benefit amount Binding: Benefit Type Codes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

Differential View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription. inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription. inv-dh-eob-03: One of subType or item.category SHALL be present. inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy'). inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
meta |  | 1..1 | Meta | Metadata about the resource
profile |  | 1..* | uri | Profiles this resource claims to conform to
identifier | S | 1..1 | Identifier | Business Identifier
status | S | 0..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active
type | S | 0..1 | CodeableConcept | Type or discipline
subType | S | 0..* | CodeableConcept | Finer grained claim type information Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
patient | S | 1..1 | Reference(AU Base Patient) | The subject of the Products and Services
created | S | 1..1 | dateTime | Creation date
insurer |  | 0..1 | Reference(AU Base Organisation) | Insurer responsible for the EOB
provider | S | 0..1 | Reference(AU Base Practitioner) | Responsible provider for the claim
organization |  | 0..1 | Reference(AU Base Organisation) | Responsible organization for the claim
referral | S | 0..1 | Reference(ADHA MBS DVA ReferralRequest) {c} | Treatment Referral
prescription | S | 0..1 | Reference(ADHA PBS MedicationRequest) {c} | Prescription authorizing services or products
item | S | 1..1 | BackboneElement | Goods and Services
sequence | S | 1..1 | positiveInt | Service instance Fixed Value: 1
category | S | 0..1 | CodeableConcept | Type of service or product Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
service | S | 1..1 | CodeableConcept | Billing Code Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
serviced[x] | S | 1..1 | date, Period | Date or dates of Service
quantity | S | 0..1 | SimpleQuantity | Count of Products or Services
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription. inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription. inv-dh-eob-03: One of subType or item.category SHALL be present. inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy'). inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
profile | Σ | 1..* | uri | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: Common Languages (extensible): A human language.
Additional Bindings | Purpose
All Languages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..1 | Identifier | Business Identifier
status | ?!S Σ | 0..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. Fixed Value: active
type | S | 0..1 | CodeableConcept | Type or discipline Binding: Example Claim Type Codes (required): The type or discipline-style of the claim
subType | S | 0..* | CodeableConcept | Finer grained claim type information Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
patient | S | 1..1 | Reference(AU Base Patient) | The subject of the Products and Services
billablePeriod |  | 0..1 | Period | Period for charge submission
created | S | 1..1 | dateTime | Creation date
enterer |  | 0..1 | Reference(Practitioner) | Author
insurer |  | 0..1 | Reference(AU Base Organisation) | Insurer responsible for the EOB
provider | S | 0..1 | Reference(AU Base Practitioner) | Responsible provider for the claim
organization |  | 0..1 | Reference(AU Base Organisation) | Responsible organization for the claim
referral | S | 0..1 | Reference(ADHA MBS DVA ReferralRequest) {c} | Treatment Referral
facility |  | 0..1 | Reference(Location) | Servicing Facility
claim |  | 0..1 | Reference(Claim) | Claim reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome |  | 0..1 | CodeableConcept | complete | error | partial Binding: Claim Processing Codes (example): The result of the claim processing
disposition |  | 0..1 | string | Disposition Message
related |  | 0..* | BackboneElement | Related Claims which may be revelant to processing this claim
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: Example Related Claim Relationship Codes (example): Relationship of this claim to a related Claim
reference |  | 0..1 | Identifier | Related file or case reference
prescription | S | 0..1 | Reference(ADHA PBS MedicationRequest) {c} | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Party to be paid any benefits payable
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 0..1 | CodeableConcept | Type of party: Subscriber, Provider, other Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
resourceType |  | 0..1 | CodeableConcept | organization | patient | practitioner | relatedperson Binding: PayeeResourceType (required): The type of payee Resource
party |  | 0..1 | Reference(Practitioner | Organization | Patient | RelatedPerson) | Party to receive the payable
information |  | 0..* | BackboneElement | Exceptions, special considerations, the condition, situation, prior or concurrent issues
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Information instance identifier
category |  | 1..1 | CodeableConcept | General class of information Binding: Claim Information Category Codes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: Exception Codes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Additional Data or supporting information
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Reason associated with the information Binding: Missing Tooth Reason Codes (example): Reason codes for the missing teeth
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Number to covey order of careteam
provider |  | 1..1 | Reference(Practitioner | Organization) | Member of the Care Team
responsible |  | 0..1 | boolean | Billing practitioner
role |  | 0..1 | CodeableConcept | Role on the team Binding: Claim Care Team Role Codes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Type, classification or Specialization Binding: Example Provider Qualification Codes (example): Provider professional qualifications
diagnosis |  | 0..* | BackboneElement | List of Diagnosis
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Number to covey order of diagnosis
diagnosis[x] |  | 1..1 |  | Patient's diagnosis Binding: ICD-10 Codes (example): ICD10 Diagnostic codes
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (example): The type of the diagnosis: admitting, principal, discharge
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (example): The DRG codes associated with the diagnosis
procedure |  | 0..* | BackboneElement | Procedures performed
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Procedure sequence for reference
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Patient's list of procedures performed Binding: ICD-10 Procedure Codes (example): ICD10 Procedure codes
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
insurance |  | 0..1 | BackboneElement | Insurance or medical plan
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
coverage |  | 0..1 | Reference(Coverage) | Insurance information
preAuthRef |  | 0..* | string | Pre-Authorization/Determination Reference
accident |  | 0..1 | BackboneElement | Details of an accident
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
date |  | 0..1 | date | When the accident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (required): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Accident Place
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
employmentImpacted |  | 0..1 | Period | Period unable to work
hospitalization |  | 0..1 | Period | Period in hospital
item | S | 1..1 | BackboneElement | Goods and Services
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence | S | 1..1 | positiveInt | Service instance Fixed Value: 1
careTeamLinkId |  | 0..* | positiveInt | Applicable careteam members
diagnosisLinkId |  | 0..* | positiveInt | Applicable diagnoses
procedureLinkId |  | 0..* | positiveInt | Applicable procedures
informationLinkId |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category | S | 0..1 | CodeableConcept | Type of service or product Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
service | S | 1..1 | CodeableConcept | Billing Code Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
serviced[x] | S | 1..1 |  | Date or dates of Service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service Binding: Example Service Place Codes (example): Place where the service is rendered
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
bodySite |  | 0..1 | CodeableConcept | Service Location Binding: Oral Site Codes (example): The code for the teeth, quadrant, sextant and arch
subSite |  | 0..* | CodeableConcept | Service Sub-location Binding: Surface Codes (example): The code for the tooth surface and surface combinations
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
category |  | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Binding: Adjudication Value Codes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of Adjudication outcome Binding: Adjudication Reason Codes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitory value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Service instance
type |  | 1..1 | CodeableConcept | Group or type of product or service Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
quantity |  | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total additional item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequence |  | 1..1 | positiveInt | Service instance
type |  | 1..1 | CodeableConcept | Type of product or service Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program specific reason for item inclusion Binding: Example Program Reason Codes (example): Program specific reason codes
quantity |  | 0..1 | SimpleQuantity | Count of Products or Services
unitPrice |  | 0..1 | Money | Fee, charge or cost per point
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Net additional item cost
udi |  | 0..* | Reference(Device) | Unique Device Identifier
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Language if different from the resource
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
sequenceLinkId |  | 0..* | positiveInt | Service instances
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
fee |  | 0..1 | Money | Professional fee or Product charge
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Added items details
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Type of service or product Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
service |  | 0..1 | CodeableConcept | Billing Code Binding: USCLS Codes (example): Allowable service and product codes
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
fee |  | 0..1 | Money | Professional fee or Product charge
noteNumber |  | 0..* | positiveInt | List of note numbers which apply
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items detail adjudication
totalCost |  | 0..1 | Money | Total Cost of service from the Claim
unallocDeductable |  | 0..1 | Money | Unallocated deductable
totalBenefit |  | 0..1 | Money | Total benefit payable for the Claim
payment |  | 0..1 | BackboneElement | Payment (if paid)
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 0..1 | CodeableConcept | Partial or Complete Binding: Example Payment Type Codes (example): The type (partial, complete) of the payment
adjustment |  | 0..1 | Money | Payment adjustment for non-Claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Binding: Payment Adjustment Reason Codes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of Payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Identifier of the payment instrument
form |  | 0..1 | CodeableConcept | Printed Form Identifier Binding: Form Codes (example): The forms codes.
processNote |  | 0..* | BackboneElement | Processing notes
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
number |  | 0..1 | positiveInt | Sequence number for this note
type |  | 0..1 | CodeableConcept | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanitory text
language |  | 0..1 | CodeableConcept | Language if different from the resource Binding: Common Languages (extensible): A human language.
Additional Bindings | Purpose
All Languages | Max Binding
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
category |  | 1..1 | CodeableConcept | Type of services covered Binding: Benefit Category Codes (example): Benefit categories such as: oral, medical, vision etc.
subCategory |  | 0..1 | CodeableConcept | Detailed services covered within the type Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: Network Type Codes (example): Code to classify in or out of network services
unit |  | 0..1 | CodeableConcept | Individual or family Binding: Unit Type Codes (example): Unit covered/serviced - individual or family
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: Benefit Term Codes (example): Coverage unit - annual, lifetime
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional Content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored
type |  | 1..1 | CodeableConcept | Deductable, visits, benefit amount Binding: Benefit Type Codes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

#### 1.0.2 Quick Start

Below is an overview of the required search and read operations.

Summary of Search Criteria for StructureDefinition-explanationofbenefit-medicare

none defined