STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Explanationofbenefit-example.ttl

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General Person Primary Coverage EOB Example

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xs: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir//ExplanationOfBenefit/EB3500> a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "EB3500"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ]
  ];
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/explanationofbenefit" ];
     fhir:Identifier.value [ fhir:value "987654321" ]
  ];
  fhir:ExplanationOfBenefit.claimReference [
     fhir:reference <http://hl7.org/fhir/Claim/100150>;
     fhir:Reference.reference [ fhir:value "Claim/100150" ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2014-08-16"^^xs:date];
  fhir:ExplanationOfBenefit.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ExplanationOfBenefit.organizationReference [
     fhir:reference <http://hl7.org/fhir/Organization/2>;
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:ExplanationOfBenefit.patientReference [
     fhir:reference <http://hl7.org/fhir/Patient/pat1>;
     fhir:Reference.reference [ fhir:value "Patient/pat1" ]
  ];
  fhir:ExplanationOfBenefit.coverage [
     fhir:ExplanationOfBenefit.coverage.coverageReference [
       fhir:reference <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]     ]
  ];
  fhir:ExplanationOfBenefit.item [
     fhir:index 0;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xs:int ];
     fhir:ExplanationOfBenefit.item.type [
       fhir:Coding.code [ fhir:value "service" ]     ];
     fhir:ExplanationOfBenefit.item.providerReference [
       fhir:reference <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]     ];
     fhir:ExplanationOfBenefit.item.service [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/service-uscls" ];
       fhir:Coding.code [ fhir:value "1200" ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2014-08-16"^^xs:date ];
     fhir:ExplanationOfBenefit.item.unitPrice [
       fhir:Quantity.value [ fhir:value "135.57"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Quantity.value [ fhir:value "135.57"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:Coding.code [ fhir:value "eligible" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "120.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:Coding.code [ fhir:value "eligpercent" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.value [ fhir:value "0.80"^^xs:decimal ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:Coding.code [ fhir:value "benefit" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "96.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ExplanationOfBenefit.totalCost [
     fhir:Quantity.value [ fhir:value "135.57"^^xs:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ fhir:value "USD" ]
  ];
  fhir:ExplanationOfBenefit.totalBenefit [
     fhir:Quantity.value [ fhir:value "96.00"^^xs:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ fhir:value "USD" ]
  ].

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Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.