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 |
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:
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