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.
An EOB response contains many fields. You can see an exhaustive list and explanation of each field in the HL7 FHIR documentation.
Indicates the type of EOB, either institutional, professional, or pharmacy
cancelled, see Payment for details about whether the claim was approved
The patient for whom the claim was generated
The provider who rendered the service including NPI codes
Pertinent diagnosis information typically coded as ICD-10-CM
Clinical procedures performed typically coded as ICD-10-CM or CPT
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
Additional information codes such as admission type, discharge status, DRG, or refill number
Payment details including an adjudication status of
Including the amount the insurer paid and the amount the patient paid out-of-pocket
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:
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:
The total submitted amount for the claim or group or line item.
Amount of the change which is considered for adjudication.
Amount deducted from the eligible amount prior to adjudication.
Amount payable under the coverage
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%.
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.
Prior payer paid
The reduction in the payment amount to reflect the carrier as a secondary payer.
Paid by patient
The total amount paid by the patient without specifying the source.
Paid by patient - cash
The amount paid by the patient using cash, check, or other personal account.
Paid by patient - other
The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.
Paid to patient
paid to patient
Paid to provider
The amount paid to the provider.
The amount of the member's liability.
The amount of the discount
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
You can download a file with a broad set of EOB examples here.
Explanation of Benefit is available in the via the following request: Flexpa API
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
$PATIENT_ID wildcard as a search parameter.
This is a sample request using
curl "https://api.flexpa.com/fhir/ExplanationOfBenefit?patient=$PATIENT_ID" \
-H "Authorization: Bearer $ACCESS_TOKEN"
The full list of search parameters can be found here. Some of the most important are:
The ID of the patient for whom the explanation of benefits was generated. We recommend using this search parameter along with the
The type of claim. Can be one of the following:
The date the EOB was created. Can be a date range, e.g.
The status of the EOB. Can be one of the following:
"unknown". Draft ExplanationOfBenefits are not commonly available today.
This is a sample response from Humana using in Flexpa APItest mode