haau3-explanation-of-benefit-outpatient
type: ExplanationOfBenefit
node role: treeRoot
resource.id:
  value: haau3-explanation-of-benefit-outpatient
resource.meta:
  meta.profile:
    value: https://haau3.com/fhir/StructureDefinition/haau3-explanation-of-benefit
    index: 0
    link: https://haau3.com/fhir/StructureDefinition/haau3-explanation-of-benefit
  meta.profile:
    value: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional
    index: 1
    link: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional
domain resource.text:
  narrative.status:
    value: generated
  narrative.div: Generated Narrative: ExplanationOfBenefit haau3-explanation-of-benefit-outpatient 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 - Focal Coverage * true Coverage: 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 - Sequence ProductOrService Serviced[x] * 1 EXAMPLE01 2026-02-01 total category: submitted Amounts - Value Currency * 412.5 United States dollar Generated Narrative: Organization #ExampleClaimProviderOrganization active: true name: Valley Outpatient Center
domain resource.contained: Organization
  index: 0
  resource.id:
    value: ExampleClaimProviderOrganization
  organization.active:
    value: true
  organization.name:
    value: Valley Outpatient Center
explanation of benefit.identifier:
  index: 0
  identifier.system:
    value: https://haau3.com/fhir/NamingSystem/source-resource-id
  identifier.value:
    value: ExplanationOfBenefit/example-source-record
explanation of benefit.identifier:
  index: 1
  identifier.system:
    value: https://bluebutton.cms.gov/resources/variables/clm_id
  identifier.value:
    value: EXAMPLE-CLM-0001
explanation of benefit.status:
  value: active
explanation of benefit.type:
  codeable concept.coding:
    index: 0
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/claim-type
    coding.code:
      value: institutional
explanation of benefit.use:
  value: claim
explanation of benefit.patient:
  link: https://haau3.com/fhir/Patient/haau3-patient
  reference.reference:
    value: Patient/haau3-patient
explanation of benefit.created:
  value: 2026-02-04
explanation of benefit.insurer:
  reference.identifier:
    identifier.system:
      value: urn:oid:2.16.840.1.113883.4.4
    identifier.value:
      value: EXAMPLE-INSURER
explanation of benefit.provider:
  reference.reference:
    value: #ExampleClaimProviderOrganization
explanation of benefit.outcome:
  value: complete
explanation of benefit.insurance:
  index: 0
  explanation of benefit.insurance.focal:
    value: true
  explanation of benefit.insurance.coverage:
    link: https://haau3.com/fhir/Coverage/haau3-coverage-two-payors
    reference.reference:
      value: Coverage/haau3-coverage-two-payors
explanation of benefit.item:
  index: 0
  explanation of benefit.item.sequence:
    value: 1
  explanation of benefit.item.product or service:
    codeable concept.coding:
      index: 0
      coding.system:
        value: https://bluebutton.cms.gov/resources/codesystem/hcpcs
      coding.code:
        value: EXAMPLE01
  explanation of benefit.item.serviced date:
    value: 2026-02-01
explanation of benefit.total:
  index: 0
  explanation of benefit.total.category:
    codeable concept.coding:
      index: 0
      coding.code:
        value: submitted
  explanation of benefit.total.amount:
    money.value:
      value: 412.5
    money.currency:
      value: USD