ExplanationOfBenefit

Overview

The ExplanationOfBenefit resource represents the adjudicated claims and benefit determinations within the Payer Patient Access API. It provides detailed information about healthcare services rendered, coverage decisions, and payment determinations made by the payer.

Key Use Cases:

Retrieve claim adjudication details
Access benefit determination information
Support member cost-sharing calculations
Track payment and coverage decisions

Relationships to Other Resources:

Patient - The individual who received the healthcare services
Coverage - Insurance coverage used for the claim
Claim - Original claim that was adjudicated
Organization - Healthcare provider or payer organization

Resource Schema

Key fields in the ExplanationOfBenefit resource:

{
  "resourceType": "ExplanationOfBenefit",
  "id": "string",
  "identifier": [
    {
      "system": "http://example.org/eob-id",
      "value": "eob-123456"
    }
  ],
  "status": "active|cancelled|draft|entered-in-error",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional",
        "display": "Professional"
      }
    ]
  },
  "use": "claim|preauthorization|predetermination",
  "patient": {
    "reference": "Patient/patient-123"
  },
  "created": "2023-10-15T10:30:00Z",
  "insurer": {
    "reference": "Organization/insurer-456"
  },
  "provider": {
    "reference": "Organization/provider-789"
  },
  "outcome": "complete|error|partial",
  "disposition": "Claim processed successfully",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-123"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
            "code": "1",
            "display": "Medical care"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "99213",
            "display": "Office visit"
          }
        ]
      },
      "servicedDate": "2023-10-10",
      "unitPrice": {
        "value": 150.00,
        "currency": "USD"
      },
      "net": {
        "value": 150.00,
        "currency": "USD"
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible",
                "display": "Eligible Amount"
              }
            ]
          },
          "amount": {
            "value": 120.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit",
                "display": "Benefit Amount"
              }
            ]
          },
          "amount": {
            "value": 96.00,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted",
            "display": "Submitted Amount"
          }
        ]
      },
      "amount": {
        "value": 150.00,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit",
            "display": "Benefit Amount"
          }
        ]
      },
      "amount": {
        "value": 96.00,
        "currency": "USD"
      }
    }
  ]
}

Key Fields:

status - Current status of the explanation of benefit
patient - Reference to the patient who received services
created - When the EOB was created
insurer - Reference to the insurance organization
item - Details of services and adjudication

Operations

Read

Retrieve a specific explanation of benefit by ID.

Production
Preview

GET /ExplanationOfBenefit/{id}

Example Request
curl -X GET https://fhir.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/eob-123 \
    -H "Accept: application/fhir+json"

GET /ExplanationOfBenefit/{id}

Example Request
curl -X GET https://fhirtest.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/eob-123 \
    -H "Accept: application/fhir+json"

Search

Search for explanations of benefit using various criteria.

GET Method

Use GET for simple searches with parameters in the query string.

Production
Preview

GET /ExplanationOfBenefit?parameter=value

GET /ExplanationOfBenefit?parameter=value

POST Method

Use POST for complex searches with form-encoded parameters.

Production
Preview

POST /ExplanationOfBenefit/_search

POST /ExplanationOfBenefit/_search

Search Parameters

Patient-based Search:

Parameter	Type	Required	Description	Example
`patient`	reference	Yes	REQUIRED The patient for the explanation of benefit	`patient=Patient/patient-123`
`created`	date	No	When the EOB was created	`created=2023-10-15`
`identifier`	token	No	Unique identifier for the EOB	`identifier=eob-123456`
`status`	token	No	Status of the explanation of benefit	`status=active`

ID-based Search:

Parameter	Type	Required	Description	Example
`created`	date	No	When the EOB was created	`created=2023-10-15`
`identifier`	token	No	Unique identifier for the EOB	`identifier=eob-123456`
`status`	token	No	Status of the explanation of benefit	`status=active`

Common Search Patterns

Find EOBs for a patient:

GET /ExplanationOfBenefit?patient=Patient/patient-123&_count=10

Search by identifier:

GET /ExplanationOfBenefit?patient=Patient/patient-123&identifier=eob-123456

Search by creation date range:

GET /ExplanationOfBenefit?patient=Patient/patient-123&created=ge2023-01-01&created=le2023-12-31

Search by status:

GET /ExplanationOfBenefit?patient=Patient/patient-123&status=active

Examples

Request Examples

Production
Preview

Search by patient
curl -X POST https://fhir.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&_count=10"

Search by identifier
curl -X POST https://fhir.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&identifier=eob-123456"

Search by date range
curl -X POST https://fhir.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&created=ge2023-01-01&created=le2023-12-31"

Search by patient
curl -X POST https://fhirtest.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&_count=10"

Search by identifier
curl -X POST https://fhirtest.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&identifier=eob-123456"

Search by date range
curl -X POST https://fhirtest.netsmartcloud.com/payer/patient-access/v2/{tenant-id}/ExplanationOfBenefit/_search \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/patient-123&created=ge2023-01-01&created=le2023-12-31"

Response Examples

Successful Search Response

ExplanationOfBenefit Search Bundle
{
  "resourceType": "Bundle",
  "type": "searchset",
  "total": 1,
  "entry": [
    {
      "resource": {
        "resourceType": "ExplanationOfBenefit",
        "id": "eob-123",
        "identifier": [
          {
            "system": "http://example.org/eob-id",
            "value": "eob-123456"
          }
        ],
        "status": "active",
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/claim-type",
              "code": "professional",
              "display": "Professional"
            }
          ]
        },
        "use": "claim",
        "patient": {
          "reference": "Patient/patient-123"
        },
        "created": "2023-10-15T10:30:00Z",
        "insurer": {
          "reference": "Organization/insurer-456"
        },
        "provider": {
          "reference": "Organization/provider-789"
        },
        "outcome": "complete",
        "disposition": "Claim processed successfully",
        "insurance": [
          {
            "focal": true,
            "coverage": {
              "reference": "Coverage/coverage-123"
            }
          }
        ],
        "item": [
          {
            "sequence": 1,
            "category": {
              "coding": [
                {
                  "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
                  "code": "1",
                  "display": "Medical care"
                }
              ]
            },
            "productOrService": {
              "coding": [
                {
                  "system": "http://www.ama-assn.org/go/cpt",
                  "code": "99213",
                  "display": "Office visit"
                }
              ]
            },
            "servicedDate": "2023-10-10",
            "unitPrice": {
              "value": 150.00,
              "currency": "USD"
            },
            "net": {
              "value": 150.00,
              "currency": "USD"
            },
            "adjudication": [
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code": "eligible",
                      "display": "Eligible Amount"
                    }
                  ]
                },
                "amount": {
                  "value": 120.00,
                  "currency": "USD"
                }
              },
              {
                "category": {
                  "coding": [
                    {
                      "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code": "benefit",
                      "display": "Benefit Amount"
                    }
                  ]
                },
                "amount": {
                  "value": 96.00,
                  "currency": "USD"
                }
              }
            ]
          }
        ],
        "total": [
          {
            "category": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                  "code": "submitted",
                  "display": "Submitted Amount"
                }
              ]
            },
            "amount": {
              "value": 150.00,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                  "code": "benefit",
                  "display": "Benefit Amount"
                }
              ]
            },
            "amount": {
              "value": 96.00,
              "currency": "USD"
            }
          }
        ]
      }
    }
  ]
}

Individual ExplanationOfBenefit Response

Single ExplanationOfBenefit Resource
{
  "resourceType": "ExplanationOfBenefit",
  "id": "eob-456",
  "identifier": [
    {
      "system": "http://example.org/eob-id",
      "value": "eob-789012"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "pharmacy",
        "display": "Pharmacy"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-123"
  },
  "created": "2023-09-20T14:15:00Z",
  "insurer": {
    "reference": "Organization/insurer-456"
  },
  "provider": {
    "reference": "Organization/pharmacy-123"
  },
  "outcome": "complete",
  "disposition": "Prescription claim processed",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-123"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
            "code": "2",
            "display": "Prescription drugs"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code": "197361",
            "display": "Lisinopril 10 MG Oral Tablet"
          }
        ]
      },
      "servicedDate": "2023-09-15",
      "quantity": {
        "value": 30,
        "unit": "tablets"
      },
      "unitPrice": {
        "value": 25.00,
        "currency": "USD"
      },
      "net": {
        "value": 25.00,
        "currency": "USD"
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible",
                "display": "Eligible Amount"
              }
            ]
          },
          "amount": {
            "value": 25.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit",
                "display": "Benefit Amount"
              }
            ]
          },
          "amount": {
            "value": 20.00,
            "currency": "USD"
          }
        }
      ]
    }
  ]
}

Empty Result Set

No ExplanationOfBenefit Found
{
  "resourceType": "Bundle",
  "type": "searchset",
  "total": 0,
  "entry": []
}

Integration Patterns

Common Workflows

1. Member Claims History

# Step 1: Get all EOBs for patient
GET /ExplanationOfBenefit?patient=Patient/patient-123

# Step 2: Filter by date range for recent claims
GET /ExplanationOfBenefit?patient=Patient/patient-123&created=ge2023-01-01

# Step 3: Get specific EOB details
GET /ExplanationOfBenefit/eob-123

2. Claim Status Verification

# Step 1: Search by claim identifier
GET /ExplanationOfBenefit?patient=Patient/patient-123&identifier=eob-123456

# Step 2: Check claim status
GET /ExplanationOfBenefit?patient=Patient/patient-123&status=active

# Step 3: Get related coverage information
GET /Coverage/coverage-123

Patient - The individual who received the healthcare services
Coverage - Insurance coverage used for the claim
Claim - Original claim that was adjudicated
Organization - Healthcare provider or payer organization

Include Parameters

Use _include and _revinclude to fetch related resources:

# Get EOBs with patient details
GET /ExplanationOfBenefit?patient=Patient/patient-123&_include=ExplanationOfBenefit:patient

# Get EOBs with coverage details
GET /ExplanationOfBenefit?patient=Patient/patient-123&_include=ExplanationOfBenefit:coverage

Error Handling

The ExplanationOfBenefit resource follows standard FHIR error handling patterns. For detailed error responses and troubleshooting guidance, see the Common Errors page.