Release 4B

This page is part of the FHIR Specification (v4.3.0: R4B - STU). 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

Explanationofbenefit-example.ttl

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

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 -------------------------------------------------------------------

<http://hl7.org/fhir/ExplanationOfBenefit/EB3500> a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "EB3500"];
  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</div>"
  ];
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/explanationofbenefit" ];
     fhir:Identifier.value [ fhir:value "987654321" ]
  ];
  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.use [ fhir:value "claim"];
  fhir:ExplanationOfBenefit.patient [
     fhir:link <http://hl7.org/fhir/Patient/pat1>;
     fhir:Reference.reference [ fhir:value "Patient/pat1" ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ExplanationOfBenefit.enterer [
     fhir:link <http://hl7.org/fhir/Practitioner/1>;
     fhir:Reference.reference [ fhir:value "Practitioner/1" ]
  ];
  fhir:ExplanationOfBenefit.insurer [
     fhir:link <http://hl7.org/fhir/Organization/3>;
     fhir:Reference.reference [ fhir:value "Organization/3" ]
  ];
  fhir:ExplanationOfBenefit.provider [
     fhir:link <http://hl7.org/fhir/Practitioner/1>;
     fhir:Reference.reference [ fhir:value "Practitioner/1" ]
  ];
  fhir:ExplanationOfBenefit.payee [
     fhir:ExplanationOfBenefit.payee.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
         fhir:Coding.code [ fhir:value "provider" ]
       ]
     ];
     fhir:ExplanationOfBenefit.payee.party [
       fhir:link <http://hl7.org/fhir/Organization/2>;
       fhir:Reference.reference [ fhir:value "Organization/2" ]
     ]
  ];
  fhir:ExplanationOfBenefit.facility [
     fhir:link <http://hl7.org/fhir/Location/1>;
     fhir:Reference.reference [ fhir:value "Location/1" ]
  ];
  fhir:ExplanationOfBenefit.claim [
     fhir:link <http://hl7.org/fhir/Claim/100150>;
     fhir:Reference.reference [ fhir:value "Claim/100150" ]
  ];
  fhir:ExplanationOfBenefit.claimResponse [
     fhir:link <http://hl7.org/fhir/ClaimResponse/R3500>;
     fhir:Reference.reference [ fhir:value "ClaimResponse/R3500" ]
  ];
  fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
  fhir:ExplanationOfBenefit.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ExplanationOfBenefit.careTeam [
     fhir:index 0;
     fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.careTeam.provider [
       fhir:link <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]
     ]
  ];
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ]
  ];
  fhir:ExplanationOfBenefit.item [
     fhir:index 0;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-USCLS" ];
         fhir:Coding.code [ fhir:value "1205" ]
       ]
     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.unitPrice [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.udi [
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/Device/example>;
       fhir:Reference.reference [ fhir:value "Device/example" ]
     ];
     fhir:ExplanationOfBenefit.item.encounter [
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/Encounter/example>;
       fhir:Reference.reference [ fhir:value "Encounter/example" ]
     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "120.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.value [ fhir:value "0.80"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "96.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "group" ]
       ]
     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ];
     fhir:ExplanationOfBenefit.item.detail [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.detail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:ExplanationOfBenefit.item.detail.productOrService [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "group" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.detail.net [
         fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:ExplanationOfBenefit.item.detail.udi [
         fhir:index 0;
         fhir:link <http://hl7.org/fhir/Device/example>;
         fhir:Reference.reference [ fhir:value "Device/example" ]
       ];
       fhir:ExplanationOfBenefit.item.detail.adjudication [
         fhir:index 0;
         fhir:ExplanationOfBenefit.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ExplanationOfBenefit.item.adjudication.amount [
           fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.detail.subDetail [
         fhir:index 0;
         fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.productOrService [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-USCLS" ];
             fhir:Coding.code [ fhir:value "1205" ]
           ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [
           fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.net [
           fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.udi [
           fhir:index 0;
           fhir:link <http://hl7.org/fhir/Device/example>;
           fhir:Reference.reference [ fhir:value "Device/example" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [
           fhir:index 0;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligible" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.amount [
             fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 1;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligpercent" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.value [ fhir:value "0.90"^^xsd:decimal ]
         ], [
           fhir:index 2;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "benefit" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.amount [
             fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ]
       ]
     ]
  ];
  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 "135.57"^^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 "96.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/pat1> a fhir:Patient .

<http://hl7.org/fhir/Practitioner/1> a fhir:Practitioner .

<http://hl7.org/fhir/Organization/3> a fhir:Organization .

<http://hl7.org/fhir/Organization/2> a fhir:Organization .

<http://hl7.org/fhir/Location/1> a fhir:Location .

<http://hl7.org/fhir/Claim/100150> a fhir:Claim .

<http://hl7.org/fhir/ClaimResponse/R3500> a fhir:ClaimResponse .

<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .

<http://hl7.org/fhir/Coverage/9876B1> a fhir:Coverage .

<http://hl7.org/fhir/Device/example> a fhir:Device .

<http://hl7.org/fhir/Encounter/example> a fhir:Encounter .

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

<http://hl7.org/fhir/ExplanationOfBenefit/EB3500.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ExplanationOfBenefit/EB3500.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.