Explanationofbenefit-example.xml

General Person Primary Coverage EOB Example (id = "EB3500")

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir"><id value="EB3500"/><text ><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ExplanationOfBenefit</div></text><identifier ><system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/><value value="987654321"/></identifier><status value="active"/><type ><coding ><system value="http://terminology.hl7.org/CodeSystem/claim-type"/><code value="oral"/></coding></type><use value="claim"/><patient ><referencevalue="Patient/pat1 "/></patient><created value="2014年08月16日"/><enterer ><referencevalue="Practitioner/1"/></enterer><insurer ><referencevalue="Organization/3 "/></insurer><provider ><referencevalue="Practitioner/1"/></provider><payee ><type ><coding ><system value="http://terminology.hl7.org/CodeSystem/payeetype"/><code value="provider"/></coding></type><party ><referencevalue="Organization/2 "/></party></payee><facility ><referencevalue="Location/1 "/></facility><claim ><referencevalue="Claim/100150 "/></claim><claimResponse ><referencevalue="ClaimResponse/R3500 "/></claimResponse><outcome value="complete"/><disposition value="Claim settled as per contract."/><careTeam ><sequence value="1"/><provider ><referencevalue="Practitioner/example "/></provider></careTeam><insurance ><focal value="true"/><coverage ><referencevalue="Coverage/9876B1 "/></coverage></insurance><item ><sequence value="1"/><careTeamSequence value="1"/><productOrService ><coding ><system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/><code value="1205"/></coding></productOrService><servicedDate value="2014年08月16日"/><unitPrice ><value value="135.57"/><currency value="USD"/></unitPrice><net ><value value="135.57"/><currency value="USD"/></net><udi ><referencevalue="Device/example "/></udi><encounter ><referencevalue="Encounter/example "/></encounter><adjudication ><category ><coding ><code value="eligible"/></coding></category><amount ><value value="120.00"/><currency value="USD"/></amount></adjudication><adjudication ><category ><coding ><code value="eligpercent"/></coding></category><value value="0.80"/></adjudication><adjudication ><category ><coding ><code value="benefit"/></coding></category><amount ><value value="96.00"/><currency value="USD"/></amount></adjudication></item><item ><sequence value="2"/><careTeamSequence value="1"/><productOrService ><coding ><code value="group"/></coding></productOrService><servicedDate value="2014年08月16日"/><net ><value value="200.00"/><currency value="USD"/></net><adjudication ><category ><coding ><code value="benefit"/></coding></category><amount ><value value="180.00"/><currency value="USD"/></amount></adjudication><detail ><sequence value="1"/><productOrService ><coding ><code value="group"/></coding></productOrService><net ><value value="200.00"/><currency value="USD"/></net><udi ><referencevalue="Device/example "/></udi><adjudication ><category ><coding ><code value="benefit"/></coding></category><amount ><value value="180.00"/><currency value="USD"/></amount></adjudication><subDetail ><sequence value="1"/><productOrService ><coding ><system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/><code value="1205"/></coding></productOrService><unitPrice ><value value="200.00"/><currency value="USD"/></unitPrice><net ><value value="200.00"/><currency value="USD"/></net><udi ><referencevalue="Device/example "/></udi><adjudication ><category ><coding ><code value="eligible"/></coding></category><amount ><value value="200.00"/><currency value="USD"/></amount></adjudication><adjudication ><category ><coding ><code value="eligpercent"/></coding></category><value value="0.90"/></adjudication><adjudication ><category ><coding ><code value="benefit"/></coding></category><amount ><value value="180.00"/><currency value="USD"/></amount></adjudication></subDetail></detail></item><total ><category ><coding ><code value="submitted"/></coding></category><amount ><value value="135.57"/><currency value="USD"/></amount></total><total ><category ><coding ><code value="benefit"/></coding></category><amount ><value value="96.00"/><currency value="USD"/></amount></total></ExplanationOfBenefit>