ExplanationOfBenefit

Explanation of Benefit (EOB) is a FHIR resource ( JSON example) that contains a statement from a health insurance plan describing what costs will be covered for medical care received (e.g., a medical procedure or a prescription) by a covered person.

There are three main types of EOBs:

Institutional - A claim for a inpatient or outpatient institutional care (based on UB-04)
Professional - A claim for a physician or other professional care outside of an institution (based on CMS-1500)
Pharmacy - A claim for a prescription or other pharmacy product (based on NCPDP standards)

A history of EOBs can aid in workflows where the financial aspects of care are important, such as recommending the best health insurance plans during enrollment periods or calculating the patient's liability for a newly billed service.

As a core financial resource, almost all payers make this available and is one of the most important resources Flexpa uniquely provides access to today.

#Schema

An EOB response contains many fields. You can see an exhaustive list and explanation of each field in the HL7 FHIR documentation.

Name	JSON	Description
Claim type	`type.coding[].code`	Indicates the type of EOB, either institutional, professional, or pharmacy
Status	`status`	Either `active` or `cancelled`, see Payment for details about whether the claim was approved
Patient	`patient`	The patient for whom the claim was generated
Provider	`provider`	The provider who rendered the service including NPI codes
Diagnosis	`diagnosis[]`	Pertinent diagnosis information typically coded as ICD-10-CM
Procedure	`procedure[]`	Clinical procedures performed typically coded as ICD-10-CM or CPT
Line items	`item[]`	Line item amounts, amount types and the in network or out of network payment status of the line typically coded as AMA CPT, CMS HCPCS, CMS HIPPS, or NDC
Supporting information	`supportingInfo[]`	Additional information codes such as admission type, discharge status, DRG, or refill number
Payment	`payment`	Payment details including an adjudication status of `paid`, `denied`, or `partiallypaid`
Adjudication totals	`total[]`	Including the amount the insurer paid and the amount the patient paid out-of-pocket

#Profiles

EOBs are profiled in the CARIN Blue Button 2.0 Implementation Guide to provide a standardized structure for EOBs. The following profiles are available in Flexpa:

#Adjudication totals

The adjudication totals are often important to Flexpa customers, especially for helping patients understand their out-of-pocket costs.

Payers generally standardly encode according to the CARIN Blue Button 2.0 Adjudication Value Set, which is a combination of adjudication code systems from base FHIR and CARIN BB.

It is repeated here for convenience:

Field	Title	Description
submitted	Submitted Amount	The total submitted amount for the claim or group or line item.
copay	CoPay	Patient Co-Payment
eligible	Eligible Amount	Amount of the change which is considered for adjudication.
deductible	Deductible	Amount deducted from the eligible amount prior to adjudication.
benefit	Benefit Amount	Amount payable under the coverage
coinsurance	Coinsurance	The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
noncovered	Noncovered	The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
priorpayerpaid	Prior payer paid	The reduction in the payment amount to reflect the carrier as a secondary payer.
paidbypatient	Paid by patient	The total amount paid by the patient without specifying the source.
paidbypatientcash	Paid by patient - cash	The amount paid by the patient using cash, check, or other personal account.
paidbypatientother	Paid by patient - other	The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.
paidtopatient	Paid to patient	paid to patient
paidtoprovider	Paid to provider	The amount paid to the provider.
memberliability	Member liability	The amount of the member's liability.
discount	Discount	The amount of the discount
drugcost	Drug cost	Price paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration

#Examples

You can download a file with a broad set of EOB examples here.

#API

Explanation of Benefit is available in the Flexpa API via the following request:

GET https://api.flexpa.com/fhir/ExplanationOfBenefit

#Request

While some servers may support a resource-level search without any parameters, not all do. We recommend using the format below with the patient ID via the $PATIENT_ID wildcard as a search parameter.

This is a sample request using curl

ACCESS_TOKEN=flexpa-link-access-token

curl "https://api.flexpa.com/fhir/ExplanationOfBenefit?patient=$PATIENT_ID" \
  -H "Authorization: Bearer $ACCESS_TOKEN"

#Search parameters

The full list of search parameters can be found here. Some of the most important are:

Parameters

patient: string; The ID of the patient for whom the explanation of benefits was generated. We recommend using this search parameter along with the $PATIENT_ID wildcard
type: string; The type of claim. Can be one of the following: "institutional", "oral", "pharmacy", "professional" or "vision"
created: string; The date the EOB was created. Can be a date range, e.g. created=gt2021-01-01&created=lt2021-02-01
status: string; The status of the EOB. Can be one of the following: "active", "cancelled", "draft", "entered-in-error", "unknown". Draft ExplanationOfBenefits are not commonly available today.

#Sample Response

This is a sample response from Humana using Flexpa API in test mode