ExplanationOfBenefit

Overview

The ExplanationOfBenefit (EOB) resource represents the results of a claim adjudication. It provides detailed information about what was paid, what the patient owes, and how the claim was processed.

FHIR R4 Specification

See the official HL7 specification: https://hl7.org/fhir/R4/explanationofbenefit.html

Supported Fields

Field	Type	Description
id	string	Logical ID of the resource
meta	Meta	Resource metadata
identifier	Identifier[]	Business identifiers
status	code	active, cancelled, draft, entered-in-error
type	CodeableConcept	Claim type
subType	CodeableConcept	Claim subtype
use	code	claim, preauthorization, predetermination
patient	Reference(Patient)	Patient
billablePeriod	Period	Service period
created	dateTime	Creation date
enterer	Reference	Person entering EOB
insurer	Reference(Organization)	Insurer
provider	Reference	Provider
outcome	code	queued, complete, error, partial
disposition	string	Disposition message
claim	Reference(Claim)	Original claim
claimResponse	Reference	Claim response
insurance	BackboneElement[]	Insurance coverage
item	BackboneElement[]	Service line items
adjudication	BackboneElement[]	Header adjudication
total	BackboneElement[]	Total amounts
payment	BackboneElement	Payment details
processNote	BackboneElement[]	Processing notes
benefitPeriod	Period	Benefit period
benefitBalance	BackboneElement[]	Balance by category

Search Parameters

Parameter	Type	Description	Example
_id	token	Resource ID	_id=eob-001
identifier	token	Business identifier	identifier=EOB-12345
patient	reference	Patient reference	patient=Patient/123
status	token	EOB status	status=active
created	date	Creation date	created=2024-01-25
claim	reference	Claim reference	claim=Claim/456
provider	reference	Provider	provider=Practitioner/789
insurer	reference	Insurer	insurer=Organization/123
outcome	token	Processing outcome	outcome=complete
use	token	EOB use	use=claim
disposition	string	Disposition	disposition=paid
facility	reference	Facility	facility=Location/456
coverage	reference	Coverage	coverage=Coverage/789
care-team	reference	Care team member	care-team=Practitioner/123

Examples

Create an ExplanationOfBenefit

curl -X POST http://localhost:8080/baseR4/ExplanationOfBenefit \
  -H "Content-Type: application/fhir+json" \
  -d '{
    "resourceType": "ExplanationOfBenefit",
    "status": "active",
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }]
    },
    "use": "claim",
    "patient": {
      "reference": "Patient/patient-001"
    },
    "billablePeriod": {
      "start": "2024-01-15",
      "end": "2024-01-15"
    },
    "created": "2024-01-25",
    "insurer": {
      "reference": "Organization/insurance-001"
    },
    "provider": {
      "reference": "Practitioner/practitioner-001"
    },
    "outcome": "complete",
    "disposition": "Claim processed successfully",
    "insurance": [{
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-001"
      }
    }],
    "item": [{
      "sequence": 1,
      "productOrService": {
        "coding": [{
          "system": "http://www.ama-assn.org/go/cpt",
          "code": "99213"
        }]
      },
      "adjudication": [
        {
          "category": {
            "coding": [{
              "system": "http://terminology.hl7.org/CodeSystem/adjudication",
              "code": "submitted"
            }]
          },
          "amount": {"value": 150.00, "currency": "USD"}
        },
        {
          "category": {
            "coding": [{
              "system": "http://terminology.hl7.org/CodeSystem/adjudication",
              "code": "benefit"
            }]
          },
          "amount": {"value": 100.00, "currency": "USD"}
        }
      ]
    }],
    "total": [
      {
        "category": {
          "coding": [{
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted"
          }]
        },
        "amount": {"value": 150.00, "currency": "USD"}
      },
      {
        "category": {
          "coding": [{
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit"
          }]
        },
        "amount": {"value": 100.00, "currency": "USD"}
      }
    ],
    "payment": {
      "type": {
        "coding": [{
          "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
          "code": "complete"
        }]
      },
      "date": "2024-01-28",
      "amount": {"value": 100.00, "currency": "USD"}
    }
  }'

Search ExplanationOfBenefits

# By patient
curl "http://localhost:8080/baseR4/ExplanationOfBenefit?patient=Patient/123"

# By status
curl "http://localhost:8080/baseR4/ExplanationOfBenefit?status=active"

# By outcome
curl "http://localhost:8080/baseR4/ExplanationOfBenefit?outcome=complete"

# By created date
curl "http://localhost:8080/baseR4/ExplanationOfBenefit?created=2024-01-25"

Patient Compartment

# Get all EOBs for a patient
curl "http://localhost:8080/baseR4/Patient/123/ExplanationOfBenefit"

Status Codes

Code	Display
active	Active
cancelled	Cancelled
draft	Draft
entered-in-error	Entered in Error

Outcome Codes

Code	Display	Description
queued	Queued	Still being processed
complete	Complete	Processing complete
error	Error	Processing error
partial	Partial	Partially processed

Adjudication Categories

Code	Display
submitted	Submitted Amount
copay	CoPay
eligible	Eligible Amount
deductible	Deductible
benefit	Benefit Amount