{ "resourceType" : "ExplanationOfBenefit", "id" : "PCT-AEOB-Summary-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1

Profile: PCT Advanced EOB Summary

Service Description: Example service

In Network Provider Options Link: http://example.org/out-of-network.html

status: Active

type: Estimate Summary

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

billablePeriod: 2022-01-01 --> 2022-01-01

created: 2021-10-12

insurer: Organization Umbrella Insurance Company

provider: ?rref?

outcome: Processing Complete

Insurances

-FocalCoverage
*trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

total

category: Submitted Amount

Amounts

-ValueCurrency
*200United States dollar

total

category: Member liability

Amounts

-ValueCurrency
*20United States dollar

total

category: Eligible Amount

Amounts

-ValueCurrency
*190United States dollar

ProcessNotes

-ExtensionText
*processNote disclaimer text

benefitPeriod: 2022-01-01 --> 2022-01-01

benefitBalance

category: Medical Care

unit: Individual

term: Annual

Financials

-ExtensionTypeAllowed[x]Used[x]
*Allowed$1.00 (USD)$1.00 (USD)
" }, "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription", "valueString" : "Example service" }, { "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink", "valueUrl" : "http://example.org/out-of-network.html" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse", "code" : "estimate-summary", "display" : "Estimate Summary" }] }, "use" : "predetermination", "patient" : { "reference" : "Patient/patient1001" }, "billablePeriod" : { "start" : "2022-01-01", "end" : "2022-01-01" }, "created" : "2021-10-12", "insurer" : { "reference" : "Organization/org1001" }, "provider" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode" : "not-applicable" }] }, "outcome" : "complete", "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/coverage1001" } }], "total" : [{ "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "submitted", "display" : "Submitted Amount" }] }, "amount" : { "value" : 200, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability", "display" : "Member liability" }] }, "amount" : { "value" : 20, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "eligible", "display" : "Eligible Amount" }] }, "amount" : { "value" : 190, "currency" : "USD" } }], "processNote" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass", "valueCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS", "code" : "disclaimer", "display" : "Disclaimer" }] } }], "text" : "processNote disclaimer text" }], "benefitPeriod" : { "start" : "2022-01-01", "end" : "2022-01-01" }, "benefitBalance" : [{ "category" : { "coding" : [{ "system" : "https://x12.org/codes/service-type-codes", "code" : "1", "display" : "Medical Care" }], "text" : "Medical Care" }, "unit" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit", "code" : "individual" }] }, "term" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/benefit-term", "code" : "annual" }] }, "financial" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit", "valueMoney" : { "value" : 0, "currency" : "USD" } }], "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType", "code" : "allowed" }] }, "allowedMoney" : { "value" : 1, "currency" : "USD" }, "usedMoney" : { "value" : 1, "currency" : "USD" } }] }] }