Release 4B R5 Final QA

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-draft-final: Final QA Preview for R5 - STU see ballot notes ). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Explanationofbenefit-example.ttl

Example ExplanationOfBenefit/EB3500 (Turtle)

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Raw Turtle (+ also see Turtle/RDF Format Specification )

General Person Primary Coverage EOB Example 

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/ExplanationOfBenefit/EB3500> a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "EB3500"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
  ];
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/explanationofbenefit" ];
     fhir:Identifier.value [ fhir:value "987654321" ]
  ];
  fhir:ExplanationOfBenefit.status [ fhir:value "active"];
  fhir:ExplanationOfBenefit.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "oral" ]
     ]
  ];
  fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
  fhir:ExplanationOfBenefit.patient [
     fhir:link <http://hl7.org/fhir/Patient/pat1>;
     fhir:Reference.reference [ fhir:value "Patient/pat1" ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ExplanationOfBenefit.enterer [
     fhir:link <http://hl7.org/fhir/Practitioner/1>;
     fhir:Reference.reference [ fhir:value "Practitioner/1" ]
  ];
  fhir:ExplanationOfBenefit.insurer [
     fhir:link <http://hl7.org/fhir/Organization/3>;
     fhir:Reference.reference [ fhir:value "Organization/3" ]
  ];
  fhir:ExplanationOfBenefit.provider [
     fhir:link <http://hl7.org/fhir/Practitioner/1>;
     fhir:Reference.reference [ fhir:value "Practitioner/1" ]
  ];
  fhir:ExplanationOfBenefit.payee [
     fhir:ExplanationOfBenefit.payee.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
         fhir:Coding.code [ fhir:value "provider" ]
       ]
     ];
     fhir:ExplanationOfBenefit.payee.party [
       fhir:link <http://hl7.org/fhir/Organization/2>;
       fhir:Reference.reference [ fhir:value "Organization/2" ]

[a fhir:ExplanationOfBenefit ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "EB3500"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/explanationofbenefit"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "987654321" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "oral" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "claim"] ; # 
  fhir:patient [
     fhir:reference [ fhir:v "Patient/pat1" ]
  ] ; # 
  fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # 
  fhir:enterer [
     fhir:reference [ fhir:v "Practitioner/1" ]
  ] ; # 
  fhir:insurer [
     fhir:reference [ fhir:v "Organization/3" ]
  ] ; # 
  fhir:provider [
     fhir:reference [ fhir:v "Practitioner/1" ]
  ] ; # 
  fhir:payee [
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "provider" ]
       ] )
     ] ;
     fhir:party [
       fhir:reference [ fhir:v "Organization/2" ]

     ]
  ];
  fhir:ExplanationOfBenefit.facility [
     fhir:link <http://hl7.org/fhir/Location/1>;
     fhir:Reference.reference [ fhir:value "Location/1" ]
  ];
  fhir:ExplanationOfBenefit.claim [
     fhir:link <http://hl7.org/fhir/Claim/100150>;
     fhir:Reference.reference [ fhir:value "Claim/100150" ]
  ];
  fhir:ExplanationOfBenefit.claimResponse [
     fhir:link <http://hl7.org/fhir/ClaimResponse/R3500>;
     fhir:Reference.reference [ fhir:value "ClaimResponse/R3500" ]
  ];
  fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
  fhir:ExplanationOfBenefit.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ExplanationOfBenefit.careTeam [
     fhir:index 0;
     fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.careTeam.provider [
       fhir:link <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]

  ] ; # 
  fhir:facility [
     fhir:reference [ fhir:v "Location/1" ]
  ] ; # 
  fhir:claim [
     fhir:reference [ fhir:v "Claim/100150" ]
  ] ; # 
  fhir:claimResponse [
     fhir:reference [ fhir:v "ClaimResponse/R3500" ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "Claim settled as per contract."] ; # 
  fhir:careTeam ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:provider [
       fhir:reference [ fhir:v "Practitioner/example" ]

     ]
  ];
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]

  ] ) ; # 
  fhir:insurance ( [
     fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
     fhir:coverage [
       fhir:reference [ fhir:v "Coverage/9876B1" ]

     ]
  ];
  fhir:ExplanationOfBenefit.item [
     fhir:index 0;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-USCLS" ];
         fhir:Coding.code [ fhir:value "1205" ]
       ]
     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.unitPrice [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.udi [
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/Device/example>;
       fhir:Reference.reference [ fhir:value "Device/example" ]
     ];
     fhir:ExplanationOfBenefit.item.encounter [
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/Encounter/example>;
       fhir:Reference.reference [ fhir:value "Encounter/example" ]
     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "120.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

  ] ) ; # 
  fhir:item ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-USCLS"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "1205" ]
       ] )
     ] ;
     fhir:serviced [ fhir:v "2014-08-16"^^xsd:date ] ;
     fhir:unitPrice [
       fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:net [
       fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:udi ( [
       fhir:reference [ fhir:v "Device/example" ]
     ] ) ;
     fhir:encounter ( [
       fhir:reference [ fhir:v "Encounter/example" ]
     ] ) ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "120.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.value [ fhir:value "0.80"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "96.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "0.80"^^xsd:decimal ]

       ]
     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "group" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "96.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] [
     fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
     fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:code [ fhir:v "group" ]
       ] )
     ] ;
     fhir:serviced [ fhir:v "2014-08-16"^^xsd:date ] ;
     fhir:net [
       fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ExplanationOfBenefit.item.detail [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.detail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:ExplanationOfBenefit.item.detail.productOrService [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "group" ]
         ]
       ];
       fhir:ExplanationOfBenefit.item.detail.net [
         fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:ExplanationOfBenefit.item.detail.udi [
         fhir:index 0;
         fhir:link <http://hl7.org/fhir/Device/example>;
         fhir:Reference.reference [ fhir:value "Device/example" ]
       ];
       fhir:ExplanationOfBenefit.item.detail.adjudication [
         fhir:index 0;
         fhir:ExplanationOfBenefit.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ExplanationOfBenefit.item.adjudication.amount [
           fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]

     ] ) ;
     fhir:detail ( [
       fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
       fhir:productOrService [
         fhir:coding ( [
           fhir:code [ fhir:v "group" ]
         ] )
       ] ;
       fhir:net [
         fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ] ;
       fhir:udi ( [
         fhir:reference [ fhir:v "Device/example" ]
       ] ) ;
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]

         ]
       ];
       fhir:ExplanationOfBenefit.item.detail.subDetail [
         fhir:index 0;
         fhir:ExplanationOfBenefit.item.detail.subDetail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.productOrService [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-USCLS" ];
             fhir:Coding.code [ fhir:value "1205" ]

       ] ) ;
       fhir:subDetail ( [
         fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
         fhir:productOrService [
           fhir:coding ( [
             fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-USCLS"^^xsd:anyURI ] ;
             fhir:code [ fhir:v "1205" ]
           ] )
         ] ;
         fhir:unitPrice [
           fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ] ;
         fhir:net [
           fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ] ;
         fhir:udi ( [
           fhir:reference [ fhir:v "Device/example" ]
         ] ) ;
         fhir:adjudication ( [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligible" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]

           ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.unitPrice [
           fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.net [
           fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.udi [
           fhir:index 0;
           fhir:link <http://hl7.org/fhir/Device/example>;
           fhir:Reference.reference [ fhir:value "Device/example" ]
         ];
         fhir:ExplanationOfBenefit.item.detail.subDetail.adjudication [
           fhir:index 0;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligible" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.amount [
             fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]

         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligpercent" ]
             ] )
           ] ;
           fhir:quantity [
             fhir:value [ fhir:v "0.90"^^xsd:decimal ]

           ]
         ], [
           fhir:index 1;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligpercent" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.value [ fhir:value "0.90"^^xsd:decimal ]
         ], [
           fhir:index 2;
           fhir:ExplanationOfBenefit.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "benefit" ]
             ]
           ];
           fhir:ExplanationOfBenefit.item.adjudication.amount [
             fhir:Money.value [ fhir:value "180.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]

         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "benefit" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "180.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]

           ]
         ]
       ]
     ]
  ];
  fhir:ExplanationOfBenefit.total [
     fhir:index 0;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]
       ]
     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]

         ] )
       ] )
     ] )
  ] ) ; # 
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]
       ]
     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "96.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]

  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "96.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ] .

<http://hl7.org/fhir/Patient/pat1> a fhir:Patient .

<http://hl7.org/fhir/Practitioner/1> a fhir:Practitioner .

<http://hl7.org/fhir/Organization/3> a fhir:Organization .

<http://hl7.org/fhir/Organization/2> a fhir:Organization .

<http://hl7.org/fhir/Location/1> a fhir:Location .

<http://hl7.org/fhir/Claim/100150> a fhir:Claim .

<http://hl7.org/fhir/ClaimResponse/R3500> a fhir:ClaimResponse .

<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .

<http://hl7.org/fhir/Coverage/9876B1> a fhir:Coverage .

<http://hl7.org/fhir/Device/example> a fhir:Device .

<http://hl7.org/fhir/Encounter/example> a fhir:Encounter .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ExplanationOfBenefit/EB3500.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ExplanationOfBenefit/EB3500.ttl> .

  ] )] . # 


# -------------------------------------------------------------------------------------

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.