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ExplanationOfBenefit "EB3501" Version "1"

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A human-readable rendering of the ExplanationOfBenefit for a claim that had errors, various other attributes (such as accident and hospitalization) are also completed.

{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "EB3501",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2019-01-13T15:33:21.765Z"
  },
  "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"
          }
        ]
      }
    }
  ]
}

ExplanationOfBenefit "EB3500" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the ExplanationOfBenefit

{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "EB3500",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2019-01-13T15:33:21.718Z"
  },
  "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"
              }
            ]
          },
          "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"
                      }
                    ]
                  },
                  "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"
      }
    }
  ]
}