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.

Element

Type

Occurrence

Description

date-submitted

date-time

1

The date when the claim was submitted.

patient

person

1

Information about the patient.

relationship-to-plan-member

codable-value

0..1

The relationship of the patient to the plan member. Preferred Vocabulary is relationship-types.

plan

organization

1

The plan covering this claim.

member-id

string

1

The member id of the plan member.

claim-type

codable

1

The type of the claim (medical, dental, etc.) Preferred Vocabulary is explanation-of-benefits-service-type

claim-id

string

1

The claim id.

submitted-by

organization

1

The organization that submitted this claim.

provider

organization

1

The provider that performed the services.

claim-totals

ClaimAmounts

1

A summary of the financial information about this claim.

services

Services

1..N

The service included in this claim.

ClaimAmounts

The financial information related to this claim.

Element

Type

Occurrence

Description

charged-amount

Currency

1

The amount charged.

negotiated-amount

Currency

1

The amount negotiated between the provider and the payer.

copay

Currency

1

The copayment amount.

deductible

Currency

1

The deductible amount.

amount-not-covered

Currency

0..1

The amount not covered for this service.

misc-amount

Currency

0..1

Additional amount not covered for this service.

eligible-for-benefits

Currency

1

The amount that is eligible for benefits.

percentage-covered

Percentage

1

The percentage of the eligible amount that is covered by the payer.

coinsurance

Currency

1

The amount paid by the person.

benefits-paid

Currency

1

The amount paid by the payer.

patient-responsibility

Currency

1

The remaining amount paid by the person.

Service

The information about a specific service.

Element

Type

Occurrence

Description

service-type

codable-value

1

The type of the service.

diagnosis

codable-value

0..1

The diagnosis.

procedure

codable-value

0..1

The procedure performed during this service.

start-date

date-time

1

The starting date for this service.

end-date

date-time

1

The ending date for this service.

claim-amounts

ClaimAmounts

1

The financial information for this service.

notes

string

1

Additional information about this service.