ExplanationOfBenefit Example: explanationofbenefit-example

Narrative

A human-readable rendering of the ExplanationOfBenefit

Example XML

<ExplanationOfBenefit xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" >
    <id value="EB3500"/>

    <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ExplanationOfBenefit</div>
    </text>

    <identifier>
        <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>
        <value value="987654321"/>
    </identifier>

    <status value="active"/>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="oral"/>
        </coding>
    </type>

    <use value="claim"/>

    <subject>
        <reference value="Patient/pat1"/>
    </subject>

    <created value="2014-08-16"/>

    <enterer>
        <reference value="Practitioner/1"/>
    </enterer>

    <insurer>
        <reference value="Organization/3"/>
    </insurer>

    <provider>
        <reference value="Practitioner/1"/>
    </provider>

    <payee>
        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                <code value="provider"/>
            </coding>
        </type>
        <party>
            <reference value="Organization/2"/>
        </party>
    </payee>

    <facility>
        <reference value="Location/1"/>
    </facility>

    <claim>
        <reference value="Claim/100150"/>
    </claim>

    <claimResponse>
        <reference value="ClaimResponse/R3500"/>
    </claimResponse>

    <outcome value="complete" />

    <disposition value="Claim settled as per contract."/>

    <careTeam>
        <sequence value="1"/>
        <provider>
            <reference value="Practitioner/example"/>
        </provider>
    </careTeam>

    <insurance>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
    </insurance>

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
                <code value="1205"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <unitPrice>
            <value value="135.57"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="135.57"/>
            <currency value="USD"/>
        </net>
        <udi>
            <reference value="Device/example"/>
        </udi>
        <encounter>
            <reference value="Encounter/example"/>
        </encounter>
        <adjudication>
            <category>
                <coding>
                    <code value="eligible"/>
                </coding>
            </category>
            <amount>
                <value value="120.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <code value="eligpercent"/>
                </coding>
            </category>
            <quantity>
                <value value="0.80"/>
            </quantity>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <code value="benefit"/>
                </coding>
            </category>
            <amount>
                <value value="96.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>
    </item>

    <item>
        <sequence value="2"/>
        <careTeamSequence value="1"/>
        <productOrService>
            <coding>
                <code value="group"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <net>
            <value value="200.00"/>
            <currency value="USD"/>
        </net>
        <adjudication>
            <category>
                <coding>
                    <code value="benefit"/>
                </coding>
            </category>
            <amount>
                <value value="180.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>
        <detail>
            <sequence value="1"/>
            <productOrService>
                <coding>
                    <code value="group"/>
                </coding>
            </productOrService>
            <net>
                <value value="200.00"/>
                <currency value="USD"/>
            </net>
            <udi>
                <reference value="Device/example"/>
            </udi>
            <adjudication>
                <category>
                    <coding>
                        <code value="benefit"/>
                    </coding>
                </category>
                <amount>
                    <value value="180.00"/>
                    <currency value="USD"/>
                </amount>
            </adjudication>
            <subDetail>
                <sequence value="1"/>
                <productOrService>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
                        <code value="1205"/>
                    </coding>
                </productOrService>
                <unitPrice>
                    <value value="200.00"/>
                    <currency value="USD"/>
                </unitPrice>
                <net>
                    <value value="200.00"/>
                    <currency value="USD"/>
                </net>
                <udi>
                    <reference value="Device/example"/>
                </udi>
                <adjudication>
                    <category>
                        <coding>
                            <code value="eligible"/>
                        </coding>
                    </category>
                    <amount>
                        <value value="200.00"/>
                        <currency value="USD"/>
                    </amount>
                </adjudication>
                <adjudication>
                    <category>
                        <coding>
                            <code value="eligpercent"/>
                        </coding>
                    </category>
                    <quantity>
                        <value value="0.90"/>
                    </quantity>
                </adjudication>
                <adjudication>
                    <category>
                        <coding>
                            <code value="benefit"/>
                        </coding>
                    </category>
                    <amount>
                        <value value="180.00"/>
                        <currency value="USD"/>
                    </amount>
                </adjudication>
            </subDetail>
        </detail>
    </item>

    <total>
        <category>
            <coding>
                <code value="submitted"/>
            </coding>
        </category>
        <amount>
            <value value="135.57"/>
            <currency value="USD"/>
        </amount>
    </total>

    <total>
        <category>
            <coding>
                <code value="benefit"/>
            </coding>
        </category>
        <amount>
            <value value="96.00"/>
            <currency value="USD"/>
        </amount>
    </total>

</ExplanationOfBenefit>