DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

Explanationofbenefit-example.json Raw JSON (

Raw JSON ( canonical form canonical form ) General Person Primary Coverage Example )

General Person Primary Coverage EOB Example 

{
  "resourceType": "ExplanationOfBenefit",
  "id": "R3500",

  "id": "EB3500",

  "text": {
    "status": "generated",
    "div": "<div>A human-readable rendering of the ExplanationOfBenefit</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/eob",

      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",

      "value": "987654321"
    }
  ],
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"

  "claimReference": {
    "reference": "Claim/100150"

  },
  "outcome": "complete",
  "disposition": "Claim settled as per contract.",

  "created": "2014-08-16",
  "organization": {

  "_created": {
    "fhir_comments": [
      "   \n  <claimResponseReference>\n    <reference value=\"ClaimResponse/R3500\"/>\n  </claimResponseReference>  "
    ]
  },
  "disposition": "Claim settled as per contract.",
  "organizationReference": {

    "reference": "Organization/2"
  },
  "requestOrganization": {
    "reference": "Organization/1"

  "patientReference": {
    "reference": "Patient/pat1"
  },
  "coverage": {
    "coverageReference": {
      "reference": "Coverage/9876B1"
    }
  },
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "providerReference": {
        "reference": "Practitioner/example"
      },
      "service": {
        "system": "http://hl7.org/fhir/service-uscls",
        "code": "1200"
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "adjudication": [
        {
          "category": {
            "code": "eligible"
          },
          "amount": {
            "value": 120.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "category": {
            "code": "eligpercent"
          },
          "value": 0.80
        },
        {
          "category": {
            "code": "benefit"
          },
          "amount": {
            "value": 96.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ],
  "totalCost": {
    "value": 135.57,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "totalBenefit": {
    "value": 96.00,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"

  }
}
Usage
note:
every
effort
has
been
made
to
ensure
that
the
examples
are
correct
and
useful,
but
they
are
not
a
normative
part
of
the
specification.
©
HL7.org
2011+.
FHIR
DSTU2
(v1.0.2-7202)
generated
on
Sat,
Oct
24,
2015
07:44+1100.
Links:

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.