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