This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
Example ExplanationOfBenefit/EB3501 (Turtle)
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:id [ fhir:v "EB3501"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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:identifier ( [
fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/explanationofbenefit"^^xsd:anyURI ] ;
fhir:value [ fhir:v "error-1" ]
] ) ; #
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:subType [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-claimsubtype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "emergency" ]
] )
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/pat1" ]
] ; #
fhir:billablePeriod [
fhir:start [ fhir:v "2014-02-01"^^xsd:date ] ;
fhir:end [ fhir:v "2014-03-01"^^xsd:date ]
] ; #
fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; #
fhir:enterer [
fhir:reference [ fhir:v "Practitioner/1" ]
] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/2" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/2" ]
] ; #
fhir:related ( [
fhir:reference [
fhir:system [ fhir:v "http://www.BenefitsInc.com/case-number"^^xsd:anyURI ] ;
fhir:value [ fhir:v "23-56Tu-XX-47-20150M14" ]
]
] ) ; #
fhir:prescription [
fhir:reference [ fhir:v "MedicationRequest/medrx002" ]
] ; #
fhir:originalPrescription [
fhir:reference [ fhir:v "MedicationRequest/medrx0301" ]
] ; #
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 "error"] ; #
fhir:disposition [ fhir:v "Could not process."] ; #
fhir:supportingInfo ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
fhir:code [ fhir:v "employmentimpacted" ]
] )
] ;
fhir:timing [
a fhir:Period ;
fhir:start [ fhir:v "2014-02-14"^^xsd:date ] ;
fhir:end [ fhir:v "2014-02-28"^^xsd:date ]
]
] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:category [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
fhir:code [ fhir:v "hospitalized" ]
] )
] ;
fhir:timing [
a fhir:Period ;
fhir:start [ fhir:v "2014-02-14"^^xsd:date ] ;
fhir:end [ fhir:v "2014-02-16"^^xsd:date ]
]
] ) ; #
fhir:procedure ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:date [ fhir:v "2014-02-14"^^xsd:date ] ;
fhir:procedure [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/ex-icd-10-procedures"^^xsd:anyURI ] ;
fhir:code [ fhir:v "123001" ]
] )
] ;
fhir:udi ( [
fhir:reference [ fhir:v "Device/example" ]
] )
] ) ; #
fhir:precedence [ fhir:v "2"^^xsd:positiveInteger] ; #
fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/9876B1" ]
]
] ) ; #
fhir:accident [
fhir:date [ fhir:v "2014-02-14"^^xsd:date ] ;
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "SPT" ]
] )
] ;
fhir:location [
a fhir:Reference ;
fhir:reference [ fhir:v "Location/ph" ]
]
] ; #
fhir:total ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "submitted" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "2478.57"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "0.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ; #
fhir:formCode [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/forms-codes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] )
] ; #
fhir:processNote ( [
fhir:number [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "display" ]
] )
] ;
fhir:text [ fhir:v "Invalid claim" ] ;
fhir:language [
fhir:coding ( [
fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;
fhir:code [ fhir:v "en-CA" ]
] )
]
] )] . #
# -------------------------------------------------------------------------------------
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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