Claims Eob

Professional Claims (CMS-1500)

• productOrService: CPT codes (99213 office visit, 99214 detailed visit, 99232 hospital care, 99283 ER visit moderate, 36415 venipuncture, 71046 chest X-ray 2 views).
• Place of service: office (11), hospital inpatient (21), ER (23), telehealth (02).
• Include Practitioner NPI in Claim.provider.

Institutional Claims (UB-04)

• Revenue codes in Claim.item[].revenue: 0120 (room & board semi-private), 0250 (pharmacy), 0260 (IV therapy), 0300 (laboratory), 0320 (radiology diagnostic), 0450 (ER), 0710 (operating room).
• Include admit/discharge dates in Claim.billablePeriod.
• DRG in Claim.diagnosis with type "drg" when applicable.

Pharmacy / Rx Claims

• productOrService: NDC codes (National Drug Codes).
  • Metformin 500mg: NDC 00093-7214-01
  • Lisinopril 10mg: NDC 00093-7339-01
  • Atorvastatin 20mg: NDC 00093-5057-01
  • Omeprazole 20mg: NDC 65862-0525-01
  • Albuterol inhaler: NDC 00173-0682-20
• Quantity: dispense quantity (e.g., 30 tablets, 1 inhaler).
• Days supply in supportingInfo.
• Include prescribing Practitioner reference.
• Pharmacy Organization as Claim.facility.

ClaimResponse

Adjudication result from the payer:

• Status: active, cancelled, draft, entered-in-error.
• Outcome: complete, error, partial, queued (http://hl7.org/fhir/remittance-outcome).
• Disposition: "Claim settled as per contract" or denial reason text.
• Item adjudication: Each item gets adjudication[] with categories:
  • submitted — billed amount.
  • eligible — allowed/contracted amount.
  • deductible — patient deductible portion.
  • copay — patient copay amount.
  • benefit — payer payment amount. Use http://terminology.hl7.org/CodeSystem/adjudication.
• Payment: ClaimResponse.payment with amount, date, and type (complete, partial) from http://terminology.hl7.org/CodeSystem/ex-paymenttype.
• Total: adjudication totals mirroring the item-level categories.
• Include realistic denial scenarios:
  • Authorization not obtained → outcome partial, disposition "Prior auth required".
  • Non-covered service → adjudication benefit = $0.
  • Duplicate claim → outcome error.

ExplanationOfBenefit (EOB)

Combines Claim + ClaimResponse into a patient-facing benefits explanation:

• Status: active, cancelled, draft, entered-in-error.
• Use: claim, preauthorization, predetermination.
• Type: Same as Claim type (professional, institutional, pharmacy, oral, vision).
• Outcome: complete, error, partial, queued.
• Patient / Provider / Insurer: Same references as the Claim.
• Insurance: Reference Coverage, set focal.
• Item + Adjudication: Mirror the Claim items with full adjudication breakdown (submitted, eligible, deductible, copay, benefit).
• Total: EOB.total[] with category and amount for each adjudication type.
• Payment: EOB.payment with amount and date.
• BenefitBalance: Include benefit category (http://terminology.hl7.org/CodeSystem/benefit-type) with financial limits:
  • allowed money/quantity, used money/quantity for the benefit period.
• Realistic dollar amounts (approximate US ranges):
  • Office visit: billed $150–$350, allowed $80–$200, copay $20–$50.
  • ER visit: billed $500–$5,000, allowed $300–$2,500.
  • Inpatient day: billed $2,000–$10,000, allowed $1,200–$5,000.
  • Rx (generic): billed $15–$100, copay $5–$25.
  • Rx (brand): billed $100–$1,000, copay $30–$75.

Creation Order

Claims resources depend on other resources in this order:

1. Organization (payer + provider org) — standalone
2. Practitioner — standalone
3. Patient — may reference Organization
4. Coverage — references Patient + Organization (payer)
5. Encounter, Condition, Procedure, MedicationRequest — clinical resources
6. Claim — references Patient, Coverage, Practitioner, Encounter, diagnoses
7. ClaimResponse — references Claim
8. ExplanationOfBenefit — references Patient, Coverage, Claim, Practitioner