ExplanationOfBenefit

{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://raw.githubusercontent.com/api-evangelist/cms-gov/main/json-schema/cms-gov-explanation-of-benefit-schema.json",
  "title": "ExplanationOfBenefit",
  "description": "Carin BB / HL7 FHIR R4 ExplanationOfBenefit resource — the canonical Medicare claim representation used across Blue Button 2.0, BCDA, AB2D, DPC, and BFD.",
  "type": "object",
  "required": ["resourceType", "id", "status", "type", "patient"],
  "properties": {
    "resourceType": { "type": "string", "const": "ExplanationOfBenefit" },
    "id": { "type": "string" },
    "meta": {
      "type": "object",
      "properties": {
        "lastUpdated": { "type": "string", "format": "date-time" },
        "profile": { "type": "array", "items": { "type": "string", "format": "uri" } }
      }
    },
    "status": { "type": "string", "enum": ["active", "cancelled", "draft", "entered-in-error"] },
    "type": { "$ref": "#/$defs/CodeableConcept", "description": "Claim type: carrier, dme, hha, hospice, inpatient, outpatient, pde, snf" },
    "use": { "type": "string", "enum": ["claim", "preauthorization", "predetermination"] },
    "patient": { "$ref": "#/$defs/Reference" },
    "billablePeriod": { "$ref": "#/$defs/Period" },
    "created": { "type": "string", "format": "date-time" },
    "insurer": { "$ref": "#/$defs/Reference" },
    "provider": { "$ref": "#/$defs/Reference" },
    "outcome": { "type": "string", "enum": ["queued", "complete", "error", "partial"] },
    "diagnosis": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "diagnosisCodeableConcept": { "$ref": "#/$defs/CodeableConcept" },
          "type": { "type": "array", "items": { "$ref": "#/$defs/CodeableConcept" } }
        }
      }
    },
    "procedure": { "type": "array", "items": { "type": "object" } },
    "insurance": { "type": "array", "items": { "type": "object" } },
    "item": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "productOrService": { "$ref": "#/$defs/CodeableConcept" },
          "servicedDate": { "type": "string", "format": "date" },
          "servicedPeriod": { "$ref": "#/$defs/Period" },
          "quantity": { "type": "object" },
          "unitPrice": { "$ref": "#/$defs/Money" },
          "net": { "$ref": "#/$defs/Money" },
          "adjudication": { "type": "array", "items": { "type": "object" } }
        }
      }
    },
    "total": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "category": { "$ref": "#/$defs/CodeableConcept" },
          "amount": { "$ref": "#/$defs/Money" }
        }
      }
    },
    "payment": {
      "type": "object",
      "properties": {
        "type": { "$ref": "#/$defs/CodeableConcept" },
        "amount": { "$ref": "#/$defs/Money" },
        "date": { "type": "string", "format": "date" }
      }
    }
  },
  "$defs": {
    "Reference": {
      "type": "object",
      "properties": {
        "reference": { "type": "string" },
        "identifier": { "type": "object" },
        "display": { "type": "string" }
      }
    },
    "CodeableConcept": {
      "type": "object",
      "properties": {
        "coding": {
          "type": "array",
          "items": {
            "type": "object",
            "properties": {
              "system": { "type": "string", "format": "uri" },
              "code": { "type": "string" },
              "display": { "type": "string" }
            }
          }
        },
        "text": { "type": "string" }
      }
    },
    "Period": {
      "type": "object",
      "properties": {
        "start": { "type": "string", "format": "date-time" },
        "end": { "type": "string", "format": "date-time" }
      }
    },
    "Money": {
      "type": "object",
      "properties": {
        "value": { "type": "number" },
        "currency": { "type": "string", "const": "USD" }
      }
    }
  }
}