Explanationofbenefit-example-2.json

EOB for an Claim that had errors

{
  "resourceType": "ExplanationOfBenefit",
  "id": "EB3501",
  "text": {
    "status": "generated",
    "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>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
      "value": "error-1"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "subType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code": "emergency"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/pat1"
  },
  "billablePeriod": {
    "start": "2014-02-01",
    "end": "2014-03-01"
  },
  "created": "2014-08-16",
  "enterer": {
    "reference": "Practitioner/1"
  },
  "insurer": {
    "reference": "Organization/2"
  },
  "provider": {
    "reference": "Organization/2"
  },
  "related": [
    {
      "reference": {
        "system": "http://www.BenefitsInc.com/case-number",
        "value": "23-56Tu-XX-47-20150M14"
      }
    }
  ],
  "prescription": {
    "reference": "MedicationRequest/medrx002"
  },
  "originalPrescription": {
    "reference": "MedicationRequest/medrx0301"
  },
  "facility": {
    "reference": "Location/1"
  },
  "claim": {
    "reference": "Claim/100150"
  },
  "claimResponse": {
    "reference": "ClaimResponse/R3500"
  },
  "outcome": "error",
  "disposition": "Could not process.",
  "supportingInfo": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "employmentimpacted"
          }
        ]
      },
      "timingPeriod": {
        "start": "2014-02-14",
        "end": "2014-02-28"
      }
    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "hospitalized"
          }
        ]
      },
      "timingPeriod": {
        "start": "2014-02-14",
        "end": "2014-02-16"
      }
    }
  ],
  "procedure": [
    {
      "sequence": 1,
      "date": "2014-02-14",
      "procedureCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/ex-icd-10-procedures",
            "code": "123001"
          }
        ]
      },
      "udi": [
        {
          "reference": "Device/example"
        }
      ]
    }
  ],
  "precedence": 2,
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "accident": {
    "date": "2014-02-14",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
          "code": "SPT"
        }
      ]
    },
    "locationReference": {
      "reference": "Location/ph"
    }
  },
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 2478.57,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 0.00,
        "currency": "USD"
      }
    }
  ],
  "formCode": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/forms-codes",
        "code": "2"
      }
    ]
  },
  "processNote": [
    {
      "number": 1,
      "type": "display",
      "text": "Invalid claim",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }
    }
  ]
}