Explanationofbenefit-example.json

General Person Primary Coverage EOB Example

{
  "resourceType": "ExplanationOfBenefit",
  "id": "EB3500",
  "text": {
    "status": "generated",
    "div": "<div>A human-readable rendering of the ExplanationOfBenefit</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
      "value": "987654321"
    }
  ],
  "claim": {
    "reference": "Claim/100150"
  },
  "claimResponse": {
    "reference": "ClaimResponse/R3500"
  },
  "created": "2014-08-16",
  "disposition": "Claim settled as per contract.",
  "organization": {
    "reference": "Organization/2"
  },
  "patient": {
    "reference": "Patient/pat1"
  },
  "coverage": {
    "coverage": {
      "reference": "Coverage/9876B1"
    },
    "relationship": {
      "code": "self"
    }
  },
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/example"
      },
      "service": {
        "system": "http://hl7.org/fhir/ValueSet/service-uscls",
        "code": "1200"
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "adjudication": [
        {
          "category": {
            "code": "eligible"
          },
          "amount": {
            "value": 120.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "category": {
            "code": "eligpercent"
          },
          "value": 0.80
        },
        {
          "category": {
            "code": "benefit"
          },
          "amount": {
            "value": 96.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ],
  "claimTotal": {
    "value": 135.57,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "totalBenefit": {
    "value": 96.00,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  }
}