Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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

Example ExplanationOfBenefit/EB3501 (Turtle)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw Turtle (+ also see Turtle/RDF Format Specification)

EOB for an Claim that had errors

@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 xsd: <http://www.w3.org/2001/XMLSchema#> .

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

[a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "EB3501"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<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>"
  ];
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/explanationofbenefit" ];
     fhir:Identifier.value [ fhir:value "error-1" ]
  ];
  fhir:ExplanationOfBenefit.status [ fhir:value "active"];
  fhir:ExplanationOfBenefit.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "oral" ]
     ]
  ];
  fhir:ExplanationOfBenefit.subType [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-claimsubtype" ];
       fhir:Coding.code [ fhir:value "emergency" ]
     ]
  ];
  fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
  fhir:ExplanationOfBenefit.patient [
     fhir:Reference.reference [ fhir:value "Patient/pat1" ]
  ];
  fhir:ExplanationOfBenefit.billablePeriod [
     fhir:Period.start [ fhir:value "2014-02-01"^^xsd:date ];
     fhir:Period.end [ fhir:value "2014-03-01"^^xsd:date ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ExplanationOfBenefit.enterer [
     fhir:Reference.reference [ fhir:value "Practitioner/1" ]
  ];
  fhir:ExplanationOfBenefit.insurer [
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:ExplanationOfBenefit.provider [
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:ExplanationOfBenefit.related [
     fhir:index 0;
     fhir:ExplanationOfBenefit.related.reference [
       fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/case-number" ];
       fhir:Identifier.value [ fhir:value "23-56Tu-XX-47-20150M14" ]
     ]
  ];
  fhir:ExplanationOfBenefit.prescription [
     fhir:Reference.reference [ fhir:value "MedicationRequest/medrx002" ]
  ];
  fhir:ExplanationOfBenefit.originalPrescription [
     fhir:Reference.reference [ fhir:value "MedicationRequest/medrx0301" ]
  ];
  fhir:ExplanationOfBenefit.facility [
     fhir:Reference.reference [ fhir:value "Location/1" ]
  ];
  fhir:ExplanationOfBenefit.claim [
     fhir:Reference.reference [ fhir:value "Claim/100150" ]
  ];
  fhir:ExplanationOfBenefit.claimResponse [
     fhir:Reference.reference [ fhir:value "ClaimResponse/R3500" ]
  ];
  fhir:ExplanationOfBenefit.outcome [ fhir:value "error"];
  fhir:ExplanationOfBenefit.disposition [ fhir:value "Could not process."];
  fhir:ExplanationOfBenefit.supportingInfo [
     fhir:index 0;
     fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.supportingInfo.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ];
         fhir:Coding.code [ fhir:value "employmentimpacted" ]
       ]
     ];
     fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [
       fhir:Period.start [ fhir:value "2014-02-14"^^xsd:date ];
       fhir:Period.end [ fhir:value "2014-02-28"^^xsd:date ]
     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.supportingInfo.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ];
         fhir:Coding.code [ fhir:value "hospitalized" ]
       ]
     ];
     fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [
       fhir:Period.start [ fhir:value "2014-02-14"^^xsd:date ];
       fhir:Period.end [ fhir:value "2014-02-16"^^xsd:date ]
     ]
  ];
  fhir:ExplanationOfBenefit.procedure [
     fhir:index 0;
     fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2014-02-14"^^xsd:date ];
     fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/ex-icd-10-procedures" ];
         fhir:Coding.code [ fhir:value "123001" ]
       ]
     ];
     fhir:ExplanationOfBenefit.procedure.udi [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Device/example" ]
     ]
  ];
  fhir:ExplanationOfBenefit.precedence [ fhir:value "2"^^xsd:positiveInteger];
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ]
  ];
  fhir:ExplanationOfBenefit.accident [
     fhir:ExplanationOfBenefit.accident.date [ fhir:value "2014-02-14"^^xsd:date ];
     fhir:ExplanationOfBenefit.accident.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ];
         fhir:Coding.code [ fhir:value "SPT" ]
       ]
     ];
     fhir:ExplanationOfBenefit.accident.locationReference [
       fhir:Reference.reference [ fhir:value "Location/ph" ]
     ]
  ];
  fhir:ExplanationOfBenefit.total [
     fhir:index 0;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]
       ]
     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "2478.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]
       ]
     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ];
  fhir:ExplanationOfBenefit.formCode [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/forms-codes" ];
       fhir:Coding.code [ fhir:value "2" ]
     ]
  ];
  fhir:ExplanationOfBenefit.processNote [
     fhir:index 0;
     fhir:ExplanationOfBenefit.processNote.number [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.processNote.type [ fhir:value "display" ];
     fhir:ExplanationOfBenefit.processNote.text [ fhir:value "Invalid claim" ];
     fhir:ExplanationOfBenefit.processNote.language [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
         fhir:Coding.code [ fhir:value "en-CA" ]
       ]
     ]
  ]] .

# - ontology header ------------------------------------------------------------

[a owl:Ontology;
  owl:imports fhir:fhir.ttl] .

# -------------------------------------------------------------------------------------

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.