Explanationofbenefit-example.xml

General Person Primary Coverage EOB Example (id = "EB3500")

<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
 <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>

  <claim>
    <reference value="Claim/100150"/>
  </claim>
  
  <claimResponse>
    <reference value="ClaimResponse/R3500"/>
  </claimResponse>
  
  <created value="2014-08-16"/>

  <disposition value="Claim settled as per contract."/>
 
  <organization>
    <reference value="Organization/2"/>
  </organization>

  <patient>
    <reference value="Patient/pat1"/>
  </patient>
 
  <coverage>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
 
 <item>
   <sequence value="1"/>
   <type>
     <code value="service"/>
   </type>
   <provider>
     <reference value="Practitioner/example"/>
   </provider>
   <service>
     <system value="http://hl7.org/fhir/ValueSet/service-uscls"/>
     <code value="1200"/>
   </service>
   <servicedDate value="2014-08-16"/>
   <unitPrice>
      <value value="135.57"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
   </unitPrice> 
   <net>
      <value value="135.57"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
   </net> 
   <adjudication>
  <category>
    <code value="eligible"/>
  </category>
  <amount>
      <value value="120.00"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
  </amount> 
   </adjudication>
   <adjudication>
  <category>
    <code value="eligpercent"/>
  </category>
  <value value="0.80"/>
   </adjudication>
   <adjudication>
  <category>
    <code value="benefit"/>
  </category>
  <amount>
      <value value="96.00"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
  </amount> 
   </adjudication>
  </item>

  <claimTotal>
    <value value="135.57"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/> 
  </claimTotal>

  <totalBenefit>
    <value value="96.00"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/> 
  </totalBenefit>
  
</ExplanationOfBenefit>