haau3 FHIR Implementation Guide (HFIG)
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: haau3 Explanation of Benefit — an outpatient claim - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="haau3-explanation-of-benefit-outpatient"/>
  <meta>
    <profile
             value="https://haau3.com/fhir/StructureDefinition/haau3-explanation-of-benefit"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional"/>
  </meta>
  <text>
    <status value="generated"/>
    <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 (use: usual, ))</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>
  </text>
  <contained>
    <Organization>
      <id value="ExampleClaimProviderOrganization"/>
      <active value="true"/>
      <name value="Valley Outpatient Center"/>
    </Organization>
  </contained>
  <identifier>
    <system value="https://haau3.com/fhir/NamingSystem/source-resource-id"/>
    <value value="ExplanationOfBenefit/example-source-record"/>
  </identifier>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="EXAMPLE-CLM-0001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/haau3-patient"/>
  </patient>
  <created value="2026-02-04"/>
  <insurer>
    <identifier>
      <system value="urn:oid:2.16.840.1.113883.4.4"/>
      <value value="EXAMPLE-INSURER"/>
    </identifier>
  </insurer>
  <provider>
    <reference value="#ExampleClaimProviderOrganization"/>
  </provider>
  <outcome value="complete"/>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/haau3-coverage-two-payors"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="https://bluebutton.cms.gov/resources/codesystem/hcpcs"/>
        <code value="EXAMPLE01"/>
      </coding>
    </productOrService>
    <servicedDate value="2026-02-01"/>
  </item>
  <total>
    <category>
      <coding>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="412.5"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>