FHIR explanation of benefits API resource

Explanation of benefits

The Explanation Of Benefit (EOB) resource combines key information from a Claim, a Claim Response and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim.

The Explanation Of Benefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, Claim Response and Coverage/Eligibility information.

Abstract parent profile that includes constraints that are common to the four specific Explanation Of Benefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four concrete EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician. (*Based on the HL7 FHIR implementation guide found at https://build.fhir.org/ig/HL7/carin-bb/artifacts.html#3)

Based on

URL

https://fp.medicaid.utah.gov/ProviderClient/ExplanationOfBenefit

Sample Request

ACCEPT: application/json

AUTHORIZATION: Bearer {ACCESS_TOKEN}

Sample request

ACCESS_TOKEN=utahid-link-access-token

curl "https://fp.medicaid.utah.gov/ProviderClient/ExplanationOfBenefit/$PATIENT_ID" \
			-H "Authorization: Bearer $ACCESS_TOKEN"

Sample response

{
	"resourceType": "Bundle",
	"id": "8091fe437cd7447d96ba3ab8b937bb53",
	"meta": {
		"lastUpdated": "2021-09-13T12:49:58.903407+00:00"
	},
	"type": "searchset",
	"link": [
		{
			"relation": "next",
			"url": "https://localhost:9999/api/ExplanationOfBenefit?_count=3&patient=5a357166754b59777137634248494434654c336d68773d3d&ct=W3sidG9rZW4iOiIrUklEOn5RNlpxQU9jemxRdmJtQndBQUFBQUFBPT0jUlQ6MSNUUkM6MyNJU1Y6MiNJRU86NjU1NTEjUUNGOjQjRlBDOkFnSnlBQ1VCY2dBR0FOSVlBRWdDQUFNQkJBQmhJRHdBSlFFRUFLRXdDQUU9IiwicmFuZ2UiOnsibWluIjoiIiwibWF4IjoiRkYifX1d"
		},
		{
			"relation": "self",
			"url": "https://localhost:9999/api/ExplanationOfBenefit?_count=3&patient=5a357166754b59777137634248494434654c336d68773d3d"
		}
	],
	"entry": [
		{
			"fullUrl": "https://localhost:9999/api/ExplanationOfBenefit/b1b9c04a9dd63b13c8a9160910ad081223a99b686310b9983aeb96800d5e9879",
			"resource": {
				"resourceType": "ExplanationOfBenefit",
				"id": "b1b9c04a9dd63b13c8a9160910ad081223a99b686310b9983aeb96800d5e9879",
				"meta": {
					"versionId": "52",
					"lastUpdated": "2021-09-11T08:30:09.203+00:00",
					"source": "https://localhost:9999/documentation/glossary/DataSource",
					"tag": [
						{
							"system": "https://www.hl7.org/fhir/patient.html",
							"code": "Patient/5a357166754b59777137634248494434654c336d68773d3d"
						},
						{
							"system": "https://localhost:9999/documentation/glossary/lastRefreshedOn",
							"code": "2021-09-11T08:30:08.499Z"
						}
					]
				},
				"identifier": [
					{
						"use": "usual",
						"system": "https://localhost:9999/documentation/glossary/claim_id",
						"value": "558840872952"
					},
					{
						"system": "https://localhost:9999/documentation/glossary/source_data_id",
						"value": "CDF-EobRx-user00001-NTU4ODQwODcyOTUy"
					}
				],
				"status": "active",
				"type": {
					"coding": [
						{
							"system": "http://terminology.hl7.org/CodeSystem/claim-type",
							"code": "pharmacy",
							"display": "Pharmacy"
						}

					],
					"text": "Pharmacy"
				},
				"use": "claim",
				"patient": {
					"reference": "Patient/5a357166754b59777137634248494434654c336d68773d3d"
				},
				"created": "2020-06-11",
				"insurer": {
					"display": ""
				},
				"provider": {
					"identifier": {
						"system": "http://hl7.org/fhir/sid/us-npi",
						"value": "5337254169"
					},
					"display": "Grayce Considine"
				},
				"prescription": {
					"identifier": {
						"system": "http://hl7.org/fhir/sid/ndc",
						"value": "68968017201"
					},
					"display": "Secuado"
				},
				"facility": {
					"display": "098 Thompson Ways, Gloriaborough OH, 43603-2615"
				},
				"outcome": "complete",
				"insurance": [
					{
						"focal": true,
						"coverage": {
							"identifier": {
								"system": "https://localhost:9999/documentation/glossary/memberIdBase",
								"value": "H55416971"
							},
							"display": "Valentine Renner"
						}
					}
				],
				"item": [
					{
						"sequence": 1,
						"productOrService": {
							"coding": [
								{
									"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
									"code": "2265729",
									"display": "Secuado"
								},
								{
									"system": "https://open.fda.gov/apis/drug/ndc",
									"code": "68968017201",
									"display": "Secuado"
								}
							]
						}
					}
				],
				"total": [
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "allowedamount"
								}
							]
						},
						"amount": {
							"value": 141.67,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "cobamount"
								}
							]
						},
						"amount": {
							"value": 0,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "coinsuranceamount"
								}
							]
						},
						"amount": {
							"value": 0,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "copaymentamount"
								}
							]
						},
						"amount": {
							"value": 0,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "deductibleamount"
								}
							]
						},
						"amount": {
							"value": 0,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "noncoveredamount"
								}
							]
						},
						"amount": {
							"value": 142.51,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "patientpayamount"
								}
							]
						},
						"amount": {
							"value": 0,
							"currency": "USD"
						}
					},
					{
						"category": {
							"coding": [
								{
									"system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory",
									"code": "paymentamount"
								}
							]
						},
						"amount": {
							"value": 141.67,
							"currency": "USD"
						}
					}
				],
				"payment": {
					"type": {
						"coding": [
							{
								"system": "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode",
								"code": "paid",
								"display": "paid"
							}
						]
					},
					"date": "2020-06-12",
					"amount": {
						"value": 141.67,
						"currency": "USD"
					}
				}
			},
			"search": {
				"mode": "match"
			}
		}