ExplanationOfBenefit Example: explanationofbenefit-example-2

Narrative

A human-readable rendering of the ExplanationOfBenefit for a claim that had errors, various other attributes (such as accident and hospitalization) are also completed.

Example XML

<ExplanationOfBenefit xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" >
    <id value="EB3501"/>

    <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ExplanationOfBenefit for a claim that had errors, various other attributes (such as accident and hospitalization) are also completed.</div>
    </text>

    <identifier>
        <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>
        <value value="error-1"/>
    </identifier>

    <status value="active"/>

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

    <subType>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
            <code value="emergency"/>
        </coding>
    </subType>

    <use value="claim"/>

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

    <billablePeriod>
        <start value="2014-02-01"/>
        <end value="2014-03-01"/>
    </billablePeriod>

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

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

    <insurer>
        <reference value="Organization/2"/>
    </insurer>

    <provider>
        <reference value="Organization/2"/>
    </provider>

    <related>
        <reference>
            <system value="http://www.BenefitsInc.com/case-number"/>
            <value value="23-56Tu-XX-47-20150M14"/>
        </reference>
    </related>

    <prescription>
        <reference value="MedicationRequest/medrx002"/>
    </prescription>

    <originalPrescription>
        <reference value="MedicationRequest/medrx0301"/>
    </originalPrescription>

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

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

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

    <outcome value="error" />

    <disposition value="Could not process."/>

    <supportingInfo>
        <sequence value="1"/>
        <category>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                <code value="employmentimpacted"/>
            </coding>
        </category>
        <timingPeriod>
            <start value="2014-02-14"/>
            <end value="2014-02-28"/>
        </timingPeriod>
    </supportingInfo>

    <supportingInfo>
        <sequence value="2"/>
        <category>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                <code value="hospitalized"/>
            </coding>
        </category>
        <timingPeriod>
            <start value="2014-02-14"/>
            <end value="2014-02-16"/>
        </timingPeriod>
    </supportingInfo>

    <procedure>
        <sequence value="1"/>
        <date value="2014-02-14"/>
        <procedureCodeableConcept>
            <coding>
                <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures" />
                <code value="123001" />
            </coding>
        </procedureCodeableConcept>
        <udi>
            <reference value="Device/example"/>
        </udi>
    </procedure>

    <precedence value="2"/>

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

    <accident>
        <date value="2014-02-14"/>
        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode" />
                <code value="SPT" />
            </coding>
        </type>
        <locationReference>
            <reference value="Location/ph"/>
        </locationReference>
    </accident>

    <total>
        <category>
            <coding>
                <code value="submitted"/>
            </coding>
        </category>
        <amount>
            <value value="2478.57"/>
            <currency value="USD"/>
        </amount>
    </total>

    <total>
        <category>
            <coding>
                <code value="benefit"/>
            </coding>
        </category>
        <amount>
            <value value="0.00"/>
            <currency value="USD"/>
        </amount>
    </total>

    <formCode>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/forms-codes" />
            <code value="2" />
        </coding>
    </formCode>

    <processNote>
        <number value="1"/>
        <type>
            <coding>
                <system value="http://hl7.org/fhir/note-type"/>
                <code value="display"/>
            </coding>
        </type>
        <text value="Invalid claim"/>
        <language>
            <coding>
                <system value="urn:ietf:bcp:47" />
                <code value="en-CA" />
            </coding>
        </language>
    </processNote>
</ExplanationOfBenefit>