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

## Narrative

A human-readable rendering of the ExplanationOfBenefit

## Example XML



```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>
```