General Person Primary Coverage EOB Example

{
  "resourceType": "ExplanationOfBenefit",
  "id": "EB3500",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
      "value": "987654321"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/pat1"
  },
  "created": "2014-08-16",
  "enterer": {
    "reference": "Practitioner/1"
  },
  "insurer": {
    "reference": "Organization/3"
  },
  "provider": {
    "reference": "Practitioner/1"
  },
  "payee": {
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/payeetype",
          "code": "provider"
        }
      ]
    },
    "party": {
      "reference": "Organization/2"
    }
  },
  "facility": {
    "reference": "Location/1"
  },
  "claim": {
    "reference": "Claim/100150"
  },
  "claimResponse": {
    "reference": "ClaimResponse/R3500"
  },
  "outcome": "complete",
  "disposition": "Claim settled as per contract.",
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
            "code": "1205"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "currency": "USD"
      },
      "net": {
        "value": 135.57,
        "currency": "USD"
      },
      "udi": [
        {
          "reference": "Device/example"
        }
      ],
      "encounter": [
        {
          "reference": "Encounter/example"
        }
      ],
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 120.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 0.80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 96.00,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "sequence": 2,
      "careTeamSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "code": "group"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "net": {
        "value": 200.00,
        "currency": "USD"
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 180.00,
            "currency": "USD"
          }
        }
      ],
      "detail": [
        {
          "sequence": 1,
          "productOrService": {
            "coding": [
              {
                "code": "group"
              }
            ]
          },
          "net": {
            "value": 200.00,
            "currency": "USD"
          },
          "udi": [
            {
              "reference": "Device/example"
            }
          ],
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 180.00,
                "currency": "USD"
              }
            }
          ],
          "subDetail": [
            {
              "sequence": 1,
              "productOrService": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
                    "code": "1205"
                  }
                ]
              },
              "unitPrice": {
                "value": 200.00,
                "currency": "USD"
              },
              "net": {
                "value": 200.00,
                "currency": "USD"
              },
              "udi": [
                {
                  "reference": "Device/example"
                }
              ],
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 200.00,
                    "currency": "USD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligpercent"
                      }
                    ]
                  },
                  "value": 0.90
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "benefit"
                      }
                    ]
                  },
                  "amount": {
                    "value": 180.00,
                    "currency": "USD"
                  }
                }
              ]
            }
          ]
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 135.57,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 96.00,
        "currency": "USD"
      }
    }
  ]
}