ExplanationOfBenefit
ID: 204706
Payload:
{
"resourceType": "ExplanationOfBenefit",
"meta": {
"versionId": "1",
"lastUpdated": "2019-10-03T07:56:31.487+00:00"
},
"text": {
"status": "generated",
"div": "<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>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
"value": "error-1"
}
],
"outcome": "error",
"disposition": "Could not process.",
"created": "2014-08-16"
}
ID: 1339528
Payload:
{
"resourceType": "ExplanationOfBenefit",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-30T14:31:39.197+00:00",
"profile": [
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-claim"
]
},
"contained": [
{
"resourceType": "Coverage",
"id": "coverage",
"type": {
"text": "no_insurance"
}
}
],
"extension": [
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-ime-op-clm-val-amt-extension",
"valueMoney": {
"value": 400,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-dsh-op-clm-val-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pass-thru-per-diem-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-profnl-cmpnt-chrg-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-tot-pps-cptl-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-ip-ddctbl-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-pta-coinsrnc-lblty-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-ncvrd-chrg-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-tot-ddctn-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-dsprprtnt-shr-amt-extension",
"valueMoney": {
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"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-excptn-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-fsp-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-ime-amt-extension",
"valueMoney": {
"value": 400,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-outlier-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-old-cptl-hld-hrmls-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-drg-outlier-aprvd-pmt-amt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-blood-ddctbl-lblty-am-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-mdcr-non-pmt-rsn-cd-extension",
"valueCoding": {
"system": "https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd",
"code": "N",
"display": "All other reasons for non-payment"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-prpayamt-extension",
"valueMoney": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-fi-num-extension",
"valueIdentifier": {
"system": "https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num",
"value": "002000"
}
}
],
"identifier": [
{
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
"value": "3d1aa1df-a215-436c-b20d-a66cc991c26b"
},
{
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
"value": "99999999999"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd",
"code": "71",
"display": "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"
},
{
"system": "https://bluebutton.cms.gov/resources/codesystem/eob-type",
"code": "CARRIER",
"display": "EOB Type"
},
{
"system": "http://hl7.org/fhir/ex-claimtype",
"code": "professional",
"display": "Claim Type"
},
{
"system": "https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd",
"code": "O",
"display": "Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)"
}
]
},
"patient": {
"reference": "Patient/2000800"
},
"billablePeriod": {
"extension": [
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-claim-query-cd-extension",
"valueCoding": {
"system": "https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd",
"code": "3",
"display": "Final Bill"
}
}
],
"start": "2016-04-09T06:12:14-04:00",
"end": "2017-04-09T06:12:14-04:00"
},
"careTeam": [
{
"sequence": 1,
"provider": {
"identifier": {
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "99999999"
}
},
"role": {
"coding": [
{
"system": "http://hl7.org/fhir/claimcareteamrole",
"code": "primary",
"display": "Primary Care Practitioner"
}
]
}
}
],
"insurance": {
"coverage": {
"reference": "#coverage"
}
},
"item": [
{
"extension": [
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-rev-cntr-ndc-qty-extension",
"valueQuantity": {
"value": 0
}
}
],
"sequence": 1,
"locationCodeableConcept": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
"code": "21",
"display": "Inpatient Hospital"
}
]
}
}
],
"totalCost": {
"value": 125,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"payment": {
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
}
ID: 4db7b549-3a47-469e-9a45-97ff6f49c340
Payload:
{
"billablePeriod": {
"end": "1991-07-13T22:00:24+00:00",
"extension": [
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension",
"valueCoding": {
"code": "3",
"display": "Final Bill",
"system": "https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"
}
}
],
"start": "1990-07-13T22:00:24+00:00"
},
"careTeam": [
{
"provider": {
"identifier": {
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "99999999"
}
},
"role": {
"coding": [
{
"code": "primary",
"display": "Primary Care Practitioner",
"system": "http://hl7.org/fhir/claimcareteamrole"
}
]
},
"sequence": 1
}
],
"contained": [
{
"id": "coverage",
"resourceType": "Coverage",
"type": {
"text": "private"
}
}
],
"extension": [
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension",
"valueMoney": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension",
"valueMoney": {
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"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension",
"valueMoney": {
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"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
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"valueMoney": {
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"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension",
"valueMoney": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension",
"valueMoney": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension",
"valueCoding": {
"code": "N",
"display": "All other reasons for non-payment",
"system": "https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension",
"valueMoney": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 0
}
},
{
"url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension",
"valueIdentifier": {
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"value": "002000"
}
}
],
"identifier": [
{
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"value": "1fa5d506-c3ca-4d73-9f2f-2431bcd6d926"
},
{
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
"value": "99999999999"
}
],
"insurance": {
"coverage": {
"reference": "#coverage"
}
},
"item": [
{
"extension": [
{
"url":
"https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension",
"valueQuantity": {
"value": 0
}
}
],
"locationCodeableConcept": {
"coding": [
{
"code": "21",
"display": "Inpatient Hospital",
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"
}
]
},
"sequence": 1
}
],
"meta": {
"lastUpdated": "2019-10-30T10:49:02.284132+00:00",
"profile": [
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],
"versionId": "MTU3MjQzMjU0MjI4NDEzMjAwMA"
},
"organization": {
"identifier": {
"value": "b0e04623-b02c-3f8b-92ea-943fc4db60da"
}
},
"patient": {
"reference": "Patient/f2243092-c684-4146-acb8-ee581136332f"
},
"payment": {
"amount": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 0
}
},
"provider": {
"identifier": {
"value": "72d55446-d282-4c5b-9bfa-5d532169d5a7"
}
},
"resourceType": "ExplanationOfBenefit",
"status": "active",
"totalCost": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 125
},
"type": {
"coding": [
{
"code": "71",
"display": "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim",
"system": "https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd"
},
{
"code": "CARRIER",
"display": "EOB Type",
"system": "https://bluebutton.cms.gov/resources/codesystem/eob-type"
},
{
"code": "professional",
"display": "Claim Type",
"system": "http://hl7.org/fhir/ex-claimtype"
},
{
"code": "O",
"display": "Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)",
"system": "https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd"
}
]
}
}