Explanationofbenefit-example-2.xml

EOB for an Claim that had errors (id = "EB3501")

<?xml version="1.0" encoding="UTF-8"?>

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

  <patient> 
    <reference value="Patient/pat1"/> 
  </patient> 

  <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 value="display"/> 
    <text value="Invalid claim"/> 
    <language> 
      <coding> 
        <system value="urn:ietf:bcp:47"/> 
        <code value="en-CA"/> 
      </coding> 
    </language> 
  </processNote> 
</ExplanationOfBenefit>