Australian Digital Health Agency Medicare Records FHIR Implementation Guide 2.2.0

Australian Digital Health Agency Medicare Records FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 3.0.2. See the Directory of published versions for a list of available versions.

StructureDefinition: ADHA Medicare ExplanationOfBenefit [Active]

The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS), Department of Veterans’ Affairs (DVA), Pharmaceutical Benefits Schedule (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between Medicare repositories and the My Health Record system infrastructure in Australia.

Usage scenarios

The following are the usage scenarios expected:

  • An individual’s MBS claim item records are uploaded to the My Health Record system from a Medicare repository
  • An individual’s PBS claim item records are uploaded to the My Health Record system from a Medicare repository
Each Explanation of Benefit SHALL have
  1. a profile assertion to this profile
  2. an identifier for this explanation of benefit record
  3. a patient
  4. a creation date
  5. an identification of the Medicare benefit (subtype or item.category)
  6. an item that was claimed
  7. a date of supply or service
Must Support

In the context of this profile Must Support SHALL be interpreted as follows.

  • The system SHALL be able to store and retrieve the following elements:
    • status
    • type
    • subtype
    • created
    • provider
    • prescription
    • item
    • item.sequence
    • item.category
    • item.service
    • item.serviced
    • item.quantity
  • The system SHALL be able to take the following elements into account when performing processing:
    • identifier
    • patient
Profile-specific implementation guidance
  • The patient resource should be identified in the patient element with a logical reference, i.e. an Australian IHI
  • PBS record:
    • An ExplanationOfBenefit for a PBS record will represent prescription data as a MedicationRequest, including date of prescribing, number of repeats, and quantity
    • Generic name of a PBS item can be represented by the supplied item service code
    • Date of supply of the item is represented by item.serviced[x]
  • MBS record:
    • Whether a service was provided in a hospital is indicated by the use and value of item.location
    • Date of service is represented by item.serviced[x]
    • Provider role is represented in a contained Practitioner resource using the practitioner-classification extension

Formal Views of Profile Content

The official URL for this profile is: 

http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare

The purpose of this profile is to define a representation of a record of a claim against the Medicare Benefits Schedule (MBS), Department of Veterans’ Affairs (DVA), Pharmaceutical Benefits Schedule (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between Medicare repositories and the My Health Record system infrastructure in Australia.

This profile builds on ExplanationOfBenefit.

This profile was published on 2023-04-14 04:08:50+0000 as a active by Australian Digital Health Agency.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... meta 1..1MetaMetadata about the resource
.... profile 1..*uriProfiles this resource claims to conform to
... identifier S1..1IdentifierBusiness Identifier
... status S0..1codeactive | cancelled | draft | entered-in-error
Fixed Value: active
... type S0..1CodeableConceptType or discipline
... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... created S1..1dateTimeCreation date
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... prescription S0..1Reference(ADHA PBS MedicationRequest) {c}Prescription authorizing services or products
... item S1..1BackboneElementGoods and Services
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... quantity S0..1SimpleQuantityCount of Products or Services

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... id Σ0..1idLogical id of this artifact
... meta Σ1..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ1..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
All LanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier
... status ?!SΣ0..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


Fixed Value: active
... type S0..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required): The type or discipline-style of the claim

... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created S1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Binding: Claim Processing Codes (example): The result of the claim processing

... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: Example Related Claim Relationship Codes (example): Relationship of this claim to a related Claim

.... reference 0..1IdentifierRelated file or case reference
... prescription S0..1Reference(ADHA PBS MedicationRequest) {c}Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementParty to be paid any benefits payable
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
Binding: PayeeResourceType (required): The type of payee Resource

.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: Exception Codes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingReason associated with the information
Binding: Missing Tooth Reason Codes (example): Reason codes for the missing teeth

... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptType, classification or Specialization
Binding: Example Provider Qualification Codes (example): Provider professional qualifications

... diagnosis 0..*BackboneElementList of Diagnosis
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
Binding: ICD-10 Codes (example): ICD10 Diagnostic codes

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example): The type of the diagnosis: admitting, principal, discharge


.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example): The DRG codes associated with the diagnosis

... procedure 0..*BackboneElementProcedures performed
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example): ICD10 Procedure codes

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..1BackboneElementInsurance or medical plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElementDetails of an accident
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (required): Type of accident: work place, auto, etc.

.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item S1..1BackboneElementGoods and Services
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


.... serviced[x] S1..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Binding: Example Service Place Codes (example): Place where the service is rendered

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Binding: Oral Site Codes (example): The code for the teeth, quadrant, sextant and arch

.... subSite 0..*CodeableConceptService Sub-location
Binding: Surface Codes (example): The code for the tooth surface and surface combinations


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... sequence 1..1positiveIntService instance
...... type 1..1CodeableConceptType of product or service
Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

...... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Language if different from the resource
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementAdded items details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items detail adjudication
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment (if paid)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptPartial or Complete
Binding: Example Payment Type Codes (example): The type (partial, complete) of the payment

.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Binding: Payment Adjustment Reason Codes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... form 0..1CodeableConceptPrinted Form Identifier
Binding: Form Codes (example): The forms codes.

... processNote 0..*BackboneElementProcessing notes
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... number 0..1positiveIntSequence number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage if different from the resource
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
All LanguagesMax Binding
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... category 1..1CodeableConceptType of services covered
Binding: Benefit Category Codes (example): Benefit categories such as: oral, medical, vision etc.

.... subCategory 0..1CodeableConceptDetailed services covered within the type
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: Network Type Codes (example): Code to classify in or out of network services

.... unit 0..1CodeableConceptIndividual or family
Binding: Unit Type Codes (example): Unit covered/serviced - individual or family

.... term 0..1CodeableConceptAnnual or lifetime
Binding: Benefit Term Codes (example): Coverage unit - annual, lifetime

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... type 1..1CodeableConceptDeductable, visits, benefit amount
Binding: Benefit Type Codes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... meta 1..1MetaMetadata about the resource
.... profile 1..*uriProfiles this resource claims to conform to
... identifier S1..1IdentifierBusiness Identifier
... status S0..1codeactive | cancelled | draft | entered-in-error
Fixed Value: active
... type S0..1CodeableConceptType or discipline
... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... created S1..1dateTimeCreation date
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... prescription S0..1Reference(ADHA PBS MedicationRequest) {c}Prescription authorizing services or products
... item S1..1BackboneElementGoods and Services
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... serviced[x] S1..1date, PeriodDate or dates of Service
.... quantity S0..1SimpleQuantityCount of Products or Services

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
inv-dh-eob-01: A PBS or RPBS claim SHALL include a prescription.
inv-dh-eob-02: A MBS or DVABS claim SHALL NOT include a prescription.
inv-dh-eob-03: One of subType or item.category SHALL be present.
inv-dh-eob-04: A PBS claim SHALL be of type 'Pharmacy' (type='pharmacy').
inv-dh-eob-05: One meta.profile SHALL have value 'http://ns.electronichealth.net.au/ci/fhir/StructureDefinition/explanationofbenefit-medicare'.
... id Σ0..1idLogical id of this artifact
... meta Σ1..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... profile Σ1..*uriProfiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
All LanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier
... status ?!SΣ0..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


Fixed Value: active
... type S0..1CodeableConceptType or discipline
Binding: Example Claim Type Codes (required): The type or discipline-style of the claim

... subType S0..*CodeableConceptFiner grained claim type information
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (required)
... patient S1..1Reference(AU Base Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created S1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(AU Base Organisation)Insurer responsible for the EOB
... provider S0..1Reference(AU Base Practitioner)Responsible provider for the claim
... organization 0..1Reference(AU Base Organisation)Responsible organization for the claim
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome 0..1CodeableConceptcomplete | error | partial
Binding: Claim Processing Codes (example): The result of the claim processing

... disposition 0..1stringDisposition Message
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claim
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: Example Related Claim Relationship Codes (example): Relationship of this claim to a related Claim

.... reference 0..1IdentifierRelated file or case reference
... prescription S0..1Reference(ADHA PBS MedicationRequest) {c}Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementParty to be paid any benefits payable
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of party: Subscriber, Provider, other
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... resourceType 0..1CodeableConceptorganization | patient | practitioner | relatedperson
Binding: PayeeResourceType (required): The type of payee Resource

.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Binding: Claim Information Category Codes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: Exception Codes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingReason associated with the information
Binding: Missing Tooth Reason Codes (example): Reason codes for the missing teeth

... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of careteam
.... provider 1..1Reference(Practitioner | Organization)Member of the Care Team
.... responsible 0..1booleanBilling practitioner
.... role 0..1CodeableConceptRole on the team
Binding: Claim Care Team Role Codes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptType, classification or Specialization
Binding: Example Provider Qualification Codes (example): Provider professional qualifications

... diagnosis 0..*BackboneElementList of Diagnosis
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
Binding: ICD-10 Codes (example): ICD10 Diagnostic codes

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (example): The type of the diagnosis: admitting, principal, discharge


.... packageCode 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (example): The DRG codes associated with the diagnosis

... procedure 0..*BackboneElementProcedures performed
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
Binding: ICD-10 Procedure Codes (example): ICD10 Procedure codes

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance 0..1BackboneElementInsurance or medical plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... coverage 0..1Reference(Coverage)Insurance information
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
... accident 0..1BackboneElementDetails of an accident
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... date 0..1dateWhen the accident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (required): Type of accident: work place, auto, etc.

.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item S1..1BackboneElementGoods and Services
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequence S1..1positiveIntService instance
Fixed Value: 1
.... careTeamLinkId 0..*positiveIntApplicable careteam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category S0..1CodeableConceptType of service or product
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1 (extensible)
.... service S1..1CodeableConceptBilling Code
Binding: https://healthterminologies.gov.au/fhir/ValueSet/australian-dhs-modifications-pbs-mbs-dva-item-1 (required)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


.... serviced[x] S1..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Binding: Example Service Place Codes (example): Place where the service is rendered

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Binding: Oral Site Codes (example): The code for the teeth, quadrant, sextant and arch

.... subSite 0..*CodeableConceptService Sub-location
Binding: Surface Codes (example): The code for the tooth surface and surface combinations


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Binding: Adjudication Value Codes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Binding: Adjudication Reason Codes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... sequence 1..1positiveIntService instance
..... type 1..1CodeableConceptGroup or type of product or service
Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... sequence 1..1positiveIntService instance
...... type 1..1CodeableConceptType of product or service
Binding: ActInvoiceGroupCode (required): Service, Product, Rx Dispense, Rx Compound etc.

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

...... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Binding: Example Program Reason Codes (example): Program specific reason codes


...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Language if different from the resource
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

.... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementAdded items details
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptType of service or product
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

..... service 0..1CodeableConceptBilling Code
Binding: USCLS Codes (example): Allowable service and product codes

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items detail adjudication
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment (if paid)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptPartial or Complete
Binding: Example Payment Type Codes (example): The type (partial, complete) of the payment

.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Binding: Payment Adjustment Reason Codes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... form 0..1CodeableConceptPrinted Form Identifier
Binding: Form Codes (example): The forms codes.

... processNote 0..*BackboneElementProcessing notes
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... number 0..1positiveIntSequence number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanitory text
.... language 0..1CodeableConceptLanguage if different from the resource
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
All LanguagesMax Binding
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... category 1..1CodeableConceptType of services covered
Binding: Benefit Category Codes (example): Benefit categories such as: oral, medical, vision etc.

.... subCategory 0..1CodeableConceptDetailed services covered within the type
Binding: Benefit SubCategory Codes (example): Benefit subcategories such as: oral-basic, major, glasses

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: Network Type Codes (example): Code to classify in or out of network services

.... unit 0..1CodeableConceptIndividual or family
Binding: Unit Type Codes (example): Unit covered/serviced - individual or family

.... term 0..1CodeableConceptAnnual or lifetime
Binding: Benefit Term Codes (example): Coverage unit - annual, lifetime

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... type 1..1CodeableConceptDeductable, visits, benefit amount
Binding: Benefit Type Codes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

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Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

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Summary of Search Criteria for StructureDefinition-explanationofbenefit-medicare

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