Release
4B
5
Financial
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R4B
(v5.0.0:
R5
-
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| Financial Management Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
General Person Primary Coverage EOB Example
{
"resourceType": "ExplanationOfBenefit",
"id": "EB3500",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
"resourceType" : "ExplanationOfBenefit",
"id" : "EB3500",
"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"
}
]
"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"
"use" : "claim",
"patient" : {
"reference" : "Patient/pat1"
},
"created": "2014-08-16",
"enterer": {
"reference": "Practitioner/1"
"created" : "2014-08-16",
"enterer" : {
"reference" : "Practitioner/1"
},
"insurer": {
"reference": "Organization/3"
"insurer" : {
"reference" : "Organization/3"
},
"provider": {
"reference": "Practitioner/1"
"provider" : {
"reference" : "Practitioner/1"
},
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
"payee" : {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}]
},
"party": {
"reference": "Organization/2"
"party" : {
"reference" : "Organization/2"
}
},
"facility": {
"reference": "Location/1"
"facility" : {
"reference" : "Location/1"
},
"claim": {
"reference": "Claim/100150"
"claim" : {
"reference" : "Claim/100150"
},
"claimResponse": {
"reference": "ClaimResponse/R3500"
"claimResponse" : {
"reference" : "ClaimResponse/R3500"
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"outcome" : "complete",
"disposition" : "Claim settled as per contract.",
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"insurance": [
}],
"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"
}
},
{
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 0.80
}
}
],
"item": [
},
{
"sequence": 1,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code": "1205"
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 135.57,
"currency": "USD"
"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"
}]
},
"net": {
"value": 135.57,
"currency": "USD"
"amount" : {
"value" : 180.00,
"currency" : "USD"
}
}],
"detail" : [{
"sequence" : 1,
"productOrService" : {
"coding" : [{
"code" : "group"
}]
},
"udi": [
{
"reference": "Device/example"
}
],
"encounter": [
{
"reference": "Encounter/example"
"net" : {
"value" : 200.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "Device/example"
}],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 180.00,
"currency" : "USD"
}
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
}],
"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": 120.00,
"currency": "USD"
"amount" : {
"value" : 200.00,
"currency" : "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"value": 0.80
"quantity" : {
"value" : 0.90
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount": {
"value": 96.00,
"currency": "USD"
"amount" : {
"value" : 180.00,
"currency" : "USD"
}
}
]
}]
}]
}]
}],
"total" : [{
"category" : {
"coding" : [{
"code" : "submitted"
}]
},
{
"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"
}
}
]
}
]
}
]
"amount" : {
"value" : 135.57,
"currency" : "USD"
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 96.00,
"currency": "USD"
}
"amount" : {
"value" : 96.00,
"currency" : "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.
FHIR
®©
HL7.org
2011+.
FHIR
Release
4B
(v4.3.0)
hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0
generated
on
Sat,
May
28,
2022
12:55+1000.
Sun,
Mar
26,
2023
15:24+1100.
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