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Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
General Person Primary Coverage EOB Example
{ "resourceType" : "ExplanationOfBenefit", "id" : "EB3500", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>" }, "identifier" : [{ "system" : "http://www.BenefitsInc.com/fhir/explanationofbenefit", "value" : "987654321" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "oral" }] }, "use" : "claim", "patient" : { "reference" : "Patient/pat1" }, "created" : "2014-08-16", "enterer" : { "reference" : "Practitioner/1" }, "insurer" : { "reference" : "Organization/3" }, "provider" : { "reference" : "Practitioner/1" }, "payee" : { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/payeetype", "code" : "provider" }] }, "party" : { "reference" : "Organization/2" } }, "facility" : { "reference" : "Location/1" }, "claim" : { "reference" : "Claim/100150" }, "claimResponse" : { "reference" : "ClaimResponse/R3500" }, "outcome" : "complete", "disposition" : "Claim settled as per contract.", "careTeam" : [{ "sequence" : 1, "provider" : { "reference" : "Practitioner/example" } }], "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/9876B1" } }], "item" : [{ "sequence" : 1, "careTeamSequence" : [1], "productOrService" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code" : "1205" }] }, "servicedDate" : "2014-08-16", "unitPrice" : { "value" : 135.57, "currency" : "USD" }, "net" : { "value" : 135.57, "currency" : "USD" }, "udi" : [{ "reference" : "Device/example" }], "encounter" : [{ "reference" : "Encounter/example" }], "adjudication" : [{ "category" : { "coding" : [{ "code" : "eligible" }] }, "amount" : { "value" : 120.00, "currency" : "USD" } }, { "category" : { "coding" : [{ "code" : "eligpercent" }] }, "quantity" : { "value" : 0.80 } }, { "category" : { "coding" : [{ "code" : "benefit" }] }, "amount" : { "value" : 96.00, "currency" : "USD" } }] }, { "sequence" : 2, "careTeamSequence" : [1], "productOrService" : { "coding" : [{ "code" : "group" }] }, "servicedDate" : "2014-08-16", "net" : { "value" : 200.00, "currency" : "USD" }, "adjudication" : [{ "category" : { "coding" : [{ "code" : "benefit" }] }, "amount" : { "value" : 180.00, "currency" : "USD" } }], "detail" : [{ "sequence" : 1, "productOrService" : { "coding" : [{ "code" : "group" }] }, "net" : { "value" : 200.00, "currency" : "USD" }, "udi" : [{ "reference" : "Device/example" }], "adjudication" : [{ "category" : { "coding" : [{ "code" : "benefit" }] }, "amount" : { "value" : 180.00, "currency" : "USD" } }], "subDetail" : [{ "sequence" : 1, "productOrService" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code" : "1205" }] }, "unitPrice" : { "value" : 200.00, "currency" : "USD" }, "net" : { "value" : 200.00, "currency" : "USD" }, "udi" : [{ "reference" : "Device/example" }], "adjudication" : [{ "category" : { "coding" : [{ "code" : "eligible" }] }, "amount" : { "value" : 200.00, "currency" : "USD" } }, { "category" : { "coding" : [{ "code" : "eligpercent" }] }, "quantity" : { "value" : 0.90 } }, { "category" : { "coding" : [{ "code" : "benefit" }] }, "amount" : { "value" : 180.00, "currency" : "USD" } }] }] }] }], "total" : [{ "category" : { "coding" : [{ "code" : "submitted" }] }, "amount" : { "value" : 135.57, "currency" : "USD" } }, { "category" : { "coding" : [{ "code" : "benefit" }] }, "amount" : { "value" : 96.00, "currency" : "USD" } }] }
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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Wed, Oct 2, 2024 17:57+0000.
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