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Version 1.1.1.0
The ExplanationOfBenefit (EOB) resource is used for reporting to patients or transferring data to patient centered applications. It takes key information from the Claim resource (13.6) 
and the ClaimResponse resource (13.7) , and, optionally, from the Account resource (8.12) , stripping out any provider or payer proprietary information. This resource combines the information into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider’s organization.
EOB is not simply a series of pointers to referred-to content models; rather, it is a physical subset scoped to the adjudication by a single payer which details the services rendered, the amounts to be settled and to whom, and optionally the coverage allowed under the policy and the amounts used to date.
The ExplanationOfBenefit resource is an event resource from a FHIR workflow perspective. An event is any description of an activity that has already taken place or that is currently ongoing.
Typically the EOB is used to convey claim and response information to patients or subscribers. However, the ExplanationOfBenefits resource also encompasses Coverage/Eligibility information (13.2: Request, 13.3: Response), and may also be used to convey consolidated predetermination and preauthorization request and response information. ExplanationOfBenefit is part of the eClaim domain. Other related resources from this domain are:
The ExplanationOfBenefit is an abstract parent profile which includes constraints that are common to the four specific ExplanationOfBenefit profiles defined in the CARIN for Blue Button® Implementation Guide (1.0.0) . All EOB instances should be from one of the four concrete EOB profiles defined in the C4BB Implementation Guide:
Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The profile is used for EOBs that are based on claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for inpatient services. These claims may include the use of equipment and supplies, laboratory services, radiology services, and other charges.
The claims data for this resource profile is based on the institutional claim format UB-04. These submission standards were adopted by the Department of Health and Human Services.
Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. This profile is used for EOBs that are based on claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for outpatient services. These claims may include including the use of equipment and supplies, laboratory services, radiology services, and other charges.
The claims data for this resource profile is based on the institutional claim format UB-04. These submission standards were adopted by the Department of Health and Human Services.
This profile is used for EOBs that are based on claims submitted by retail pharmacies . The data for these claims is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program).
This profile is used for EOBs based on claims submitted by physicians, suppliers, and other non-institutional providers for professional services . These services may be rendered in inpatient or outpatient situations, including office locations.
The claims data is based on the professional claim form 1500. These submission standards were adopted by the Department of Health and Human Services as form CMS-1500.
The C4BBExplanationOfBenefit structure is derived from the FHIR R4 ExplanationOfBenefit resource. The structure refers to these other structures:
These search parameters are defined specifically for use with the ExplanationOfBenefit resource. See the links in each section below for more information about that parameter.
This parameter describes the members of the care team who provided the overall service, as well as their role, whether responsible, and qualifications. Commonly used to identify the responsible and supporting practitioners.
The ExplanationOfBenefit_Careteam parameter targets Practitioner, Organization, and PractitionerRole resources.
This parameter describes the plan under which the claim was adjudicated. The ExplanationOfBenefit_Coverage parameter targets the Coverage resource.
A unique business/claim identifier assigned to the Explanation of Benefit. Enables EOBs to be distinguished and referenced.
This is a business identifier, not a resource identifier.
This parameter describes the party responsible for authorization, adjudication and reimbursement of the claim.
To be a valid claim, preauthorization, or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
This parameter references the party to whom professional services and/or products have been supplied, or are being considered, and for whom actual for forecast reimbursement is sought. The ExplanationOfBenefit_Patient parameter targets the Patient resource.
This parameter references the provider who is responsible for the claim, predetermination, or preauthorization. The ExplanationOfBenefit_Provider parameter targets Practitioner, Organization, and PractitionerRole resources.
This provider is responsible for the claim but not necessarily professionally responsible for providing the individual products and services.
This parameter describes the date of the service for the EOB. The ExplanationOfBenefit_ServiceDate parameter is used to determine whether the service or product was provided during the term of the insurance coverage.
The service-date search parameter simplifies searching, since a client does not need to know:
This parameter describes the category of claim, the general style of a claim: for example, oral, pharmacy, vision, professional and institutional, or variants on those terms. The valueset, however, is extensible.
Claim type (ExplanationOfBenefit_Type) determine the general sets of business rules applied for information requirements and adjudication.
This parameter describes the identity of the organization the practitioner represents or acts on behalf of. The ExplanationOfBenefit_Organization parameter targets the Organization resource.
This parameter references the practitioner who is able to provide the defined services for the organization. The ExplanationOfBenefit_Practitioner parameter targets the Organization resource.
Use Postman to test Opala's Patient Access API by querying the API and returning the results. The Opala Collection is a group of API requests that are already saved in the Postman app and arranged in folders. You can access Opala's Patient Access Sandbox and, if you have the correct credentials, the production environment as well. For more information see Setting Up Postman in this documentation set.
The ExplanationOfBenefit resource encompasses Claim, ClaimResponse and Coverage/Eligibility information, and may also be used to convey predetermination and preauthorization request and response information.
Note: The Opala API does not enable a request of all ExplanationOfBenefit resources. In other words, the query [baseurl]/ExplanationOfBenefit is not allowed.
Query EOB Using a Resource
You can query the ExplanationOfBenefit resource for a specific resource like Coverage, Organization, or Patient.
[baseurl]/ExplanationOfBenefit?patient=[patientid]
Query Using the _include Parameter
_include parameter to indicate that subject resources related to the search results must be included in the results. The _include parameter must also contain a parameter to join on.
[baseurl]/Patient?_include=ExplanationOfBenefit:[join parameter]
For example, if you use :patient in the _include parameter above, the results will include any patient the ExpanationOfBenefit resource refers to.
Search For a Specific Insured Member
To search for an ExplanationOfBenefit for a specific insured member in a system, use the Object Identifier and member number.
[baseurl]/ExplanationOfBenefit?patient.identifier=[object identifier]|[member number]
resource for the elements in the ExplanationOfBenefit resource for the ExplanationOfBenefit resource for the ExplanationOfBenefit resource for the ExplanationOfBenefit resource resource profile. for the ExplanationOfBenefit resource profile for the ExplanationOfBenefit resource profile