EOB for an Claim that had errors (id = "EB3501")

<?xml version="1.0" encoding="UTF-8"?>


  

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

  
    
    
  

  

  
    
      
      
    
  

  
    
      
      
    
  

  

  
    
  

  
    
    
  

  

  
    
  

  
    
  

  
    
  

  
    
      
      
    
  

  
    
  

  
    
  

  
    
  

  
    
  

  
    
   

  

  

  
    
    
      
        
        
      
    
    
      
      
    
  

  
    
    
      
        
        
      
    
    
      
      
    
  

  
    
    
    
      
        
        
      
    
    
      
    
  

  

  
    
    
      
    
  

  
    
    
      
        
        
      
    
    
      
    
  

  
    
      
        
      
    
    
      
       
     
  

  
    
      
        
      
    
    
      
       
     
  

  
    
      
      
    
  

  
    
    
    
    
      
        
        
      
    
  

<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EB3501"/> 
  <text> 
    <status value="generated"/> 
    <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> 
  </text>   <identifier>     <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>     <value value="error-1"/>   </identifier>   <status value="active"/>   <type>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>       <code value="oral"/>     </coding>   </type>   <subType>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>       <code value="emergency"/>     </coding>   </subType>   <use value="claim"/>   <patient>     <reference value="Patient/pat1"/>   </patient>   <billablePeriod>     <start value="2014-02-01"/>     <end value="2014-03-01"/>   </billablePeriod>   <created value="2014-08-16"/>   <enterer>     <reference value="Practitioner/1"/>   </enterer>   <insurer>     <reference value="Organization/2"/>   </insurer>   <provider>     <reference value="Organization/2"/>   </provider>   <related>     <reference>       <system value="http://www.BenefitsInc.com/case-number"/>       <value value="23-56Tu-XX-47-20150M14"/>     </reference>   </related>   <prescription>     <reference value="MedicationRequest/medrx002"/>   </prescription>   <originalPrescription>     <reference value="MedicationRequest/medrx0301"/>   </originalPrescription>   <facility>     <reference value="Location/1"/>   </facility>   <claim>     <reference value="Claim/100150"/>   </claim>   <claimResponse>     <reference value="ClaimResponse/R3500"/>   </claimResponse>    <outcome value="error"/>   <disposition value="Could not process."/>   <supportingInfo>     <sequence value="1"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="employmentimpacted"/>       </coding>     </category>     <timingPeriod>       <start value="2014-02-14"/>       <end value="2014-02-28"/>     </timingPeriod>   </supportingInfo>   <supportingInfo>     <sequence value="2"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="hospitalized"/>       </coding>     </category>     <timingPeriod>       <start value="2014-02-14"/>       <end value="2014-02-16"/>     </timingPeriod>   </supportingInfo>   <procedure>     <sequence value="1"/>     <date value="2014-02-14"/>     <procedureCodeableConcept>       <coding>         <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>         <code value="123001"/>       </coding>     </procedureCodeableConcept>     <udi>       <reference value="Device/example"/>     </udi>   </procedure>   <precedence value="2"/>   <insurance>     <focal value="true"/>     <coverage>       <reference value="Coverage/9876B1"/>     </coverage>   </insurance>   <accident>     <date value="2014-02-14"/>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>         <code value="SPT"/>       </coding>     </type>     <locationReference>       <reference value="Location/ph"/>     </locationReference>   </accident>   <total>     <category>       <coding>         <code value="submitted"/>       </coding>     </category>     <amount>       <value value="2478.57"/>       <currency value="USD"/>      </amount>    </total>   <total>     <category>       <coding>         <code value="benefit"/>       </coding>     </category>     <amount>       <value value="0.00"/>       <currency value="USD"/>      </amount>    </total>   <formCode>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/>       <code value="2"/>     </coding>   </formCode>   <processNote>     <number value="1"/>     <type>       <coding>         <system value="http://hl7.org/fhir/note-type"/>         <code value="display"/>       </coding>     </type>     <text value="Invalid claim"/>     <language>       <coding>         <system value="urn:ietf:bcp:47"/>         <code value="en-CA"/>       </coding>     </language>   </processNote> 


</

ExplanationOfBenefit

>