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
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
The plan covering this claim.
member-id
string
The member id of the plan member.
claim-type
codable
The type of the claim (medical, dental, etc.) Preferred Vocabulary is
claim-id
The claim id.
submitted-by
The organization that submitted this claim.
provider
The provider that performed the services.
claim-totals
ClaimAmounts
A summary of the financial information about this claim.
services
Services
1..N
The service included in this claim.
The financial information related to this claim.
charged-amount
Currency
The amount charged.
negotiated-amount
The amount negotiated between the provider and the payer.
copay
The copayment amount.
deductible
The deductible amount.
amount-not-covered
The amount not covered for this service.
misc-amount
Additional amount not covered for this service.
eligible-for-benefits
The amount that is eligible for benefits.
percentage-covered
Percentage
The percentage of the eligible amount that is covered by the payer.
coinsurance
The amount paid by the person.
benefits-paid
The amount paid by the payer.
patient-responsibility
The remaining amount paid by the person.
Service
The information about a specific service.
service-type
The type of the service.
diagnosis
The diagnosis.
procedure
The procedure performed during this service.
start-date
The starting date for this service.
end-date
The ending date for this service.
claim-amounts
The financial information for this service.
notes
Additional information about this service.