Explanationofbenefit-example.xml

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

<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://hl7.org/fhir/ex-claimtype"/> 
      <code value="oral"/> 
    </coding> 
  </type> 

  <patient> 
    <reference value="Patient/pat1"/> 
  </patient> 

  <created value="2014-08-16"/> 

  <enterer> 
    <reference value="Practitioner/1"/> 
  </enterer> 

  <provider> 
    <reference value="Practitioner/1"/> 
  </provider> 

  <organization> 
    <reference value="Organization/2"/> 
  </organization> 

  <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."/> 

  <payee> 
    <type> 
      <coding> 
        <system value="http://hl7.org/fhir/payeetype"/> 
        <code value="provider"/> 
      </coding> 
    </type> 
    <resource> 
      <system value="http://hl7.org/fhir/resource-type-link"/> 
      <code value="organization"/> 
    </resource> 
    <party> 
      <reference value="Organization/2"/> 
    </party> 
  </payee> 

  <careTeam> 
    <sequence value="1"/> 
    <provider> 
      <reference value="Practitioner/example"/> 
    </provider> 
  </careTeam> 

  <insurance> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
  </insurance> 

  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <service> 
      <coding> 
        <system value="http://hl7.org/fhir/service-uscls"/> 
        <code value="1200"/> 
      </coding> 
    </service> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="135.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="135.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </net>  
    <encounter> 
      <reference value="Encounter/example"/> 
    </encounter> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="120.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </amount>  
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="0.80"/> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="96.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </amount>  
    </adjudication> 
  </item> 

  <totalCost> 
    <value value="135.57"/> 
    <system value="urn:iso:std:iso:4217"/> 
    <code value="USD"/>  
  </totalCost> 

  <totalBenefit> 
    <value value="96.00"/> 
    <system value="urn:iso:std:iso:4217"/> 
    <code value="USD"/>  
  </totalBenefit> 

</ExplanationOfBenefit>