Release 4 5

This page is part of the FHIR Specification (v4.0.1: R4 (v5.0.0: R5 - Mixed Normative and STU ) ). This is the current published version in it's permanent home (it will always be available at this URL). 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 R2

Explanationofbenefit-example.xml

Example ExplanationOfBenefit/EB3500 (XML)

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

Raw XML ( canonical form + also see XML Format Specification )

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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>     <reference value="Patient/pat1"/>   </patient>   <created value="2014-08-16"/>   <enterer>     <reference value="Practitioner/1"/>   </enterer>   <insurer>     <reference value="Organization/3"/>   </insurer>   <provider>     <reference value="Practitioner/1"/>   </provider>   <payee>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>         <code value="provider"/>       </coding>     </type>     <party>       <reference value="Organization/2"/>     </party>   </payee>   <facility>     <reference value="Location/1"/>   </facility>   <claim>     <reference value="Claim/100150"/>   </claim>   <claimResponse>     <reference value="ClaimResponse/R3500"/>   </claimResponse>    <outcome value="complete"/>   <disposition value="Claim settled as per contract."/>   <careTeam>     <sequence value="1"/>     <provider>       <reference value="Practitioner/example"/>     </provider>   </careTeam>   <insurance>     <focal value="true"/>     <coverage>       <reference value="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="2014-08-16"/>     <unitPrice>       <value value="135.57"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="135.57"/>       <currency value="USD"/>      </net>      <udi>       <reference value="Device/example"/>     </udi>     <encounter>       <reference value="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>       <quantity>         <value value="0.80"/>       </quantity>     </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="2014-08-16"/>     <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>         <reference value="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>           <reference value="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>           <quantity>             <value value="0.90"/>           </quantity>         </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

>

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.