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"
    }
  }]
}