CMS — Centers for Medicare & Medicaid Services · Schema

ExplanationOfBenefit

Carin BB / HL7 FHIR R4 ExplanationOfBenefit resource — the canonical Medicare claim representation used across Blue Button 2.0, BCDA, AB2D, DPC, and BFD.

HealthcareMedicareMedicaidFHIRBulk DataOpen DataGovernmentFederalClaimsInsuranceACAMarketplaceQuality

Properties

Name Type Description
resourceType string
id string
meta object
status string
type object Claim type: carrier, dme, hha, hospice, inpatient, outpatient, pde, snf
use string
patient object
billablePeriod object
created string
insurer object
provider object
outcome string
diagnosis array
procedure array
insurance array
item array
total array
payment object
View JSON Schema on GitHub

JSON Schema

cms-gov-explanation-of-benefit-schema.json Raw ↑ 
{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://raw.githubusercontent.com/api-evangelist/cms-gov/main/json-schema/cms-gov-explanation-of-benefit-schema.json",
  "title": "ExplanationOfBenefit",
  "description": "Carin BB / HL7 FHIR R4 ExplanationOfBenefit resource — the canonical Medicare claim representation used across Blue Button 2.0, BCDA, AB2D, DPC, and BFD.",
  "type": "object",
  "required": ["resourceType", "id", "status", "type", "patient"],
  "properties": {
    "resourceType": { "type": "string", "const": "ExplanationOfBenefit" },
    "id": { "type": "string" },
    "meta": {
      "type": "object",
      "properties": {
        "lastUpdated": { "type": "string", "format": "date-time" },
        "profile": { "type": "array", "items": { "type": "string", "format": "uri" } }
      }
    },
    "status": { "type": "string", "enum": ["active", "cancelled", "draft", "entered-in-error"] },
    "type": { "$ref": "#/$defs/CodeableConcept", "description": "Claim type: carrier, dme, hha, hospice, inpatient, outpatient, pde, snf" },
    "use": { "type": "string", "enum": ["claim", "preauthorization", "predetermination"] },
    "patient": { "$ref": "#/$defs/Reference" },
    "billablePeriod": { "$ref": "#/$defs/Period" },
    "created": { "type": "string", "format": "date-time" },
    "insurer": { "$ref": "#/$defs/Reference" },
    "provider": { "$ref": "#/$defs/Reference" },
    "outcome": { "type": "string", "enum": ["queued", "complete", "error", "partial"] },
    "diagnosis": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "diagnosisCodeableConcept": { "$ref": "#/$defs/CodeableConcept" },
          "type": { "type": "array", "items": { "$ref": "#/$defs/CodeableConcept" } }
        }
      }
    },
    "procedure": { "type": "array", "items": { "type": "object" } },
    "insurance": { "type": "array", "items": { "type": "object" } },
    "item": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "productOrService": { "$ref": "#/$defs/CodeableConcept" },
          "servicedDate": { "type": "string", "format": "date" },
          "servicedPeriod": { "$ref": "#/$defs/Period" },
          "quantity": { "type": "object" },
          "unitPrice": { "$ref": "#/$defs/Money" },
          "net": { "$ref": "#/$defs/Money" },
          "adjudication": { "type": "array", "items": { "type": "object" } }
        }
      }
    },
    "total": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "category": { "$ref": "#/$defs/CodeableConcept" },
          "amount": { "$ref": "#/$defs/Money" }
        }
      }
    },
    "payment": {
      "type": "object",
      "properties": {
        "type": { "$ref": "#/$defs/CodeableConcept" },
        "amount": { "$ref": "#/$defs/Money" },
        "date": { "type": "string", "format": "date" }
      }
    }
  },
  "$defs": {
    "Reference": {
      "type": "object",
      "properties": {
        "reference": { "type": "string" },
        "identifier": { "type": "object" },
        "display": { "type": "string" }
      }
    },
    "CodeableConcept": {
      "type": "object",
      "properties": {
        "coding": {
          "type": "array",
          "items": {
            "type": "object",
            "properties": {
              "system": { "type": "string", "format": "uri" },
              "code": { "type": "string" },
              "display": { "type": "string" }
            }
          }
        },
        "text": { "type": "string" }
      }
    },
    "Period": {
      "type": "object",
      "properties": {
        "start": { "type": "string", "format": "date-time" },
        "end": { "type": "string", "format": "date-time" }
      }
    },
    "Money": {
      "type": "object",
      "properties": {
        "value": { "type": "number" },
        "currency": { "type": "string", "const": "USD" }
      }
    }
  }
}