Thank you to everyone who provided scenarios, samples and ideas for this data type. Here is the draft version of this new HealthVault data type. This schema is intended to store the summary and detail you, the plan member, might find on a typical paper based statement. You will likely notice that this schema doesn’t include all the data for eligibility and remittance that you might find in 270/271 or 835/837. This was intentional as our focus is to provide the consumer relevant information. If your solution requires additional levels of support for claims related information, please let us know.
Explanation of Benefits
An Explanation of Benefits (EOB) that contains information about an insurance claim.
The date when the claim was submitted.
Information about the patient.
The relationship of the patient to the plan member. Preferred Vocabulary is relationship-types.
The plan covering this claim.
The member id of the plan member.
The type of the claim (medical, dental, etc.) Preferred Vocabulary is
The claim id.
The organization that submitted this claim.
The provider that performed the services.
A summary of the financial information about this claim.
The service included in this claim.
The financial information related to this claim.
The amount charged.
The amount negotiated between the provider and the payer.
The copayment amount.
The deductible amount.
The amount not covered for this service.
Additional amount not covered for this service.
The amount that is eligible for benefits.
The percentage of the eligible amount that is covered by the payer.
The amount paid by the person.
The amount paid by the payer.
The remaining amount paid by the person.
The information about a specific service.
The type of the service.
The procedure performed during this service.
The starting date for this service.
The ending date for this service.
The financial information for this service.
Additional information about this service.