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

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: haau3 Explanation of Benefit — an outpatient claim - JSON Representation

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "haau3-explanation-of-benefit-outpatient",
  "meta" : {
    "profile" : [
      🔗 "https://haau3.com/fhir/StructureDefinition/haau3-explanation-of-benefit",
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit haau3-explanation-of-benefit-outpatient</b></p><a name=\"haau3-explanation-of-benefit-outpatient\"> </a><a name=\"hchaau3-explanation-of-benefit-outpatient\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profiles: <a href=\"StructureDefinition-haau3-explanation-of-benefit.html\">haau3 Explanation of Benefit</a>, <code>http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional</code></p></div><p><b>identifier</b>: <code>https://haau3.com/fhir/NamingSystem/source-resource-id</code>/ExplanationOfBenefit/example-source-record, <code>https://bluebutton.cms.gov/resources/variables/clm_id</code>/EXAMPLE-CLM-0001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-haau3-patient.html\">Derrick Lin  Male, DoB: 1965-04-12 ( https://haau3.com/fhir/NamingSystem/haau3-patient-id#Haau3PatientId#example-haau3-patient\u00a0(use:\u00a0usual,\u00a0))</a></p><p><b>created</b>: 2026-02-04</p><p><b>insurer</b>: Identifier: <a href=\"http://terminology.hl7.org/7.3.0/NamingSystem-USEIN.html\" title=\"An Employer Identification Number (EIN) is also known as a Federal Tax Identification Number, and is used to identify a business entity.\">United States Employer Identification Number</a>/EXAMPLE-INSURER</p><p><b>provider</b>: <a href=\"#hchaau3-explanation-of-benefit-outpatient/ExampleClaimProviderOrganization\">Organization Valley Outpatient Center</a></p><p><b>outcome</b>: Processing Complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-haau3-coverage-two-payors.html\">Coverage: extension = -&gt;display: string (PrimitiveType/Coverage.extension[0].value[x].display): element = string -&gt; 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</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{https://bluebutton.cms.gov/resources/codesystem/hcpcs EXAMPLE01}\">EXAMPLE01</span></td><td>2026-02-01</td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:\">submitted</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>412.5</td><td>United States dollar</td></tr></table></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #ExampleClaimProviderOrganization</b></p><a name=\"haau3-explanation-of-benefit-outpatient/ExampleClaimProviderOrganization\"> </a><a name=\"hchaau3-explanation-of-benefit-outpatient/ExampleClaimProviderOrganization\"> </a><p><b>active</b>: true</p><p><b>name</b>: Valley Outpatient Center</p></blockquote></div>"
  },
  "contained" : [
    {
      "resourceType" : "Organization",
      "id" : "ExampleClaimProviderOrganization",
      "active" : true,
      "name" : "Valley Outpatient Center"
    }
  ],
  "identifier" : [
    {
      "system" : "https://haau3.com/fhir/NamingSystem/source-resource-id",
      "value" : "ExplanationOfBenefit/example-source-record"
    },
    {
      "system" : "https://bluebutton.cms.gov/resources/variables/clm_id",
      "value" : "EXAMPLE-CLM-0001"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    🔗 "reference" : "Patient/haau3-patient"
  },
  "created" : "2026-02-04",
  "insurer" : {
    "identifier" : {
      "system" : "urn:oid:2.16.840.1.113883.4.4",
      "value" : "EXAMPLE-INSURER"
    }
  },
  "provider" : {
    "reference" : "#ExampleClaimProviderOrganization"
  },
  "outcome" : "complete",
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/haau3-coverage-two-payors"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "https://bluebutton.cms.gov/resources/codesystem/hcpcs",
            "code" : "EXAMPLE01"
          }
        ]
      },
      "servicedDate" : "2026-02-01"
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "code" : "submitted"
          }
        ]
      },
      "amount" : {
        "value" : 412.5,
        "currency" : "USD"
      }
    }
  ]
}