This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes). 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
Example ExplanationOfBenefit/EB3500 (Turtle)
Raw Turtle (+ also see Turtle/RDF Format Specification)
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 xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:ExplanationOfBenefit ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "EB3500"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/explanationofbenefit"^^xsd:anyURI ] ;
fhir:value [ fhir:v "987654321" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "oral" ]
] )
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/pat1" ]
] ; #
fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; #
fhir:enterer [
fhir:reference [ fhir:v "Practitioner/1" ]
] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/3" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Practitioner/1" ]
] ; #
fhir:payee [
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ]
] )
] ;
fhir:party [
fhir:reference [ fhir:v "Organization/2" ]
]
] ; #
fhir:facility [
fhir:reference [ fhir:v "Location/1" ]
] ; #
fhir:claim [
fhir:reference [ fhir:v "Claim/100150" ]
] ; #
fhir:claimResponse [
fhir:reference [ fhir:v "ClaimResponse/R3500" ]
] ; #
fhir:outcome [ fhir:v "complete"] ; #
fhir:disposition [ fhir:v "Claim settled as per contract."] ; #
fhir:careTeam ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:reference [ fhir:v "Practitioner/example" ]
]
] ) ; #
fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/9876B1" ]
]
] ) ; #
fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:productOrService [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-USCLS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1205" ]
] )
] ;
fhir:serviced [ fhir:v "2014-08-16"^^xsd:date ] ;
fhir:unitPrice [
fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:net [
fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:udi ( [
fhir:reference [ fhir:v "Device/example" ]
] ) ;
fhir:encounter ( [
fhir:reference [ fhir:v "Encounter/example" ]
] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "120.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "0.80"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "96.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:productOrService [
fhir:coding ( [
fhir:code [ fhir:v "group" ]
] )
] ;
fhir:serviced [ fhir:v "2014-08-16"^^xsd:date ] ;
fhir:net [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ;
fhir:detail ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:productOrService [
fhir:coding ( [
fhir:code [ fhir:v "group" ]
] )
] ;
fhir:net [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:udi ( [
fhir:reference [ fhir:v "Device/example" ]
] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ;
fhir:subDetail ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:productOrService [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-USCLS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1205" ]
] )
] ;
fhir:unitPrice [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:net [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:udi ( [
fhir:reference [ fhir:v "Device/example" ]
] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "0.90"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] )
] )
] ) ; #
fhir:total ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "submitted" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "96.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )] . #
# -------------------------------------------------------------------------------------
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.
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