---
type: "example"
title: "ExplanationOfBenefit Example: explanationofbenefit-example-2"
resource: "ExplanationOfBenefit"
example: "explanationofbenefit-example-2"
---
# 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



```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>
```