haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build United States of America flag

haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example ExplanationOfBenefit: haau3 Explanation of Benefit — an outpatient claim

Profiles: haau3 Explanation of Benefit, http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional

identifier: https://haau3.com/fhir/NamingSystem/source-resource-id/ExplanationOfBenefit/example-source-record, https://bluebutton.cms.gov/resources/variables/clm_id/EXAMPLE-CLM-0001

status: Active

type: Institutional

use: Claim

patient: Derrick Lin Male, DoB: 1965-04-12 ( https://haau3.com/fhir/NamingSystem/haau3-patient-id#Haau3PatientId#example-haau3-patient (use: usual, ))

created: 2026-02-04

insurer: Identifier: United States Employer Identification Number/EXAMPLE-INSURER

provider: Organization Valley Outpatient Center

outcome: Processing Complete

Insurances

-FocalCoverage
*trueCoverage: extension = ->display: string (PrimitiveType/Coverage.extension[0].value[x].display): element = string -> display=string[Northgate Supplemental Benefits]; identifier = https://haau3.com/fhir/NamingSystem/source-resource-id#Coverage/example-source-record; status = active; subscriberId = VM-88214; relationship = 01

Items

-SequenceProductOrServiceServiced[x]
*1EXAMPLE012026-02-01

total

category: submitted

Amounts

-ValueCurrency
*412.5United States dollar

Generated Narrative: Organization #ExampleClaimProviderOrganization

active: true

name: Valley Outpatient Center