Explanation of Benefits
An Explanation of Benefits (EOB) is 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. EOBs are typically created
when providers such as hospitals, medical clinics, or pharmacies submit a claim on behalf of a covered person to their health insurance plan.
A history of EOBs can aid in workflows such as
recommending the best health insurance plans during enrollment periods.
Requirements
EOBs are directly represented in patient access APIs as a FHIR Resource. You can make HTTP
requests to Flexpa API to search for and find EOBs belonging to a particular patient. Patients authorize your
app to access their EOBs via Flexpa Link. At the end of that flow you'll have:
- An access token that is required for all requests to Flexpa API
- A patient ID that is required to query FHIR resources directly related to the patient
Searching for a patient's EOB
Searches on Flexpa API follow the RESTful style of the FHIR specification by submitting a GET HTTP request to the base URL of the resource.
To search for EOBs belonging to a particular patient, you can use an API wildcard parameter: $PATIENT_ID. Flexpa swaps this out for the real patient ID before we send the request to the right FHIR API.
You can retrieve the patient ID by either:
ACCESS_TOKEN=...
curl "https://api.flexpa.com/fhir/ExplanationOfBenefit?patient=$PATIENT_ID" \
-H "Authorization: $ACCESS_TOKEN"
Response type
The return type of querying the EOB endpoint is a searchset
bundle. Technically, a searchset bundle may contain different types of resources
(e.g., Coverage, Patient) in the entry field. When iterating through entry it is best practice to inspect each resourceType field
to ensure you are dealing with the expected resource.
Sample response
Notable fields
An EOB response contains many fields. You can get an exhaustive list and explanation of each field here.
Some notable fields:
entry - A collection of EOBs (see response type on best practice of checking resourceType)meta.lastUpdated - An ISO8601 string representing the last time the bundle was modifiedentry[i].resource.type.code[j].code - A claim type string, can
have a value of "institutional", "oral", "pharmacy", "professional" or "vision"entry[i].resource.provider - The provider (practitioner or organization)
which is responsible for the claimentry[i].resource.prescription (optional) - The prescription
to support the dispensing of pharmacy, device or vision productsentry[i].resource.total[] - Categorized monetary totals
for the adjunction
- Includes dollar amount the insurer paid
- Includes dollar amount the patient paid out-of-pocket
Next steps