To request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient. The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or If, however, both the request and the adjudication information is to be reported then theĮxplanationOfBenefit should be used instead. Request side of the information exchange is of interest. When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the Resources may contain provider and payer specific information which is not appropriate for sharing with the patient.
Should be used instead of the Claim and ClaimResponse resources as those Health Record (PHR) application, the ExplanationOfBenefit
The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient This also includes how payors may request additional supporting information from providers. Information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers Attachments and Supporting Information: how eClaims may handle the provision of supporting.RealTime Exchange and Obtaining EOBs: EOBs may be obtained using Polling or FHIR REST (SEARCH).Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.The provider will settle the claim and potentially recover costs against specified coverages. Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than.Reporting and data exchange for analytics, not just for eClaims exchange between providers and payors. Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for.status is used in the financial resources. Financial Resource Status Lifecycle: how.13.10.1.1 Additional InformationĪdditional information regarding electronic claims content and usage may be found at: The ExplanationOfBenefit resource is an "event" resource from a FHIR workflow perspective - see Workflow Event. The appropriate adjudication information for a payor response to a Claim. Note: the EOB SHALL NOT be used as a replacement for a ClaimResponse when responding to Claims. The payee is the provider as that would leak business confidential information. Note: when creating profiles for EOB as a patient focused information exchange the payment details, other than date, should be excluded if
Resolved that the ExplanationOfBenefit name has the advantage of familiarity that has been proven through the early adoption of the resource When the resource was originallyīeing developed there was substantial discussion about the adoption of an alternative name for the resource but after much discussion it was It is also recognized that "EOB" is a term that carries additional meaning in certain areas of the industry. An EOB will neverīe created for patient or subscriber information exchange if an error was detected in the Claim. Used to convey consolidated predetermination and preauthorization request and response information to patients or subscribers. Typically the EOB is only used to convey Claim (use=claim) and the associated ClaimResponse information to patients or subscribers. To whom, and optionally the coverage allowed under the policy and the amounts used to date.
Simply a series of pointers to referred-to content models, is a physical subset scoped to theĪdjudication by a single payor which details the services rendered, the amounts to be settled and In respect of a single payor prepared for consumption by the subscriber and/or patient. This is the logical combination of the Claim, ClaimResponse and some Coverage accounting information TheĮxplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resourceĮncompasses Claim, ClaimResponse and Coverage/Eligibility information. The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to informĪ patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim.