General Person Primary Coverage EOB Example (id = "EB3500")

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

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