fhir-react
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React component library for displaying FHIR Resources
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{
"resourceType": "ExplanationOfBenefit",
"id": "e6c4234b-19a8-4e5c-35cb-5d05a97d5788",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"
]
},
"related": [
{
"reference": {
"value": "Q19137E17126"
},
"claim": {
"reference": "ExplanationOfBenefit/EqUVAXt5WrNnlJPdB7swbxJXaYxxnvBxWwGPxUx1up"
},
"relationship": {
"coding": [
{
"code": "prior",
"system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"
}
]
}
},
{
"reference": {
"value": "Q19137E17126"
},
"claim": {
"reference": "ExplanationOfBenefit/ABCDEXg2WrYnlJrdr7sabxZZaYffnvBxWwGPx99999"
},
"relationship": {
"coding": [
{
"code": "replacedby",
"system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"
}
]
}
}
],
"payee": {
"type": {
"coding": [
{
"code": "provider",
"system": "http://terminology.hl7.org/CodeSystem/payeetype"
}
]
},
"party": {
"reference": "Organization/iAxXvHiphwGGAL48m3B7XXtKlLZg6yXnC1ch84x1up"
}
},
"contained": [
{
"resourceType": "ServiceRequest",
"id": "referral",
"status": "completed",
"intent": "order",
"subject": {
"reference": "Patient/f56391c2-dd54-b378-46ef-87c1643a2ba0"
},
"requester": {
"reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
},
"performer": [
{
"reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
}
]
}
],
"identifier": [
{
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
"value": "c145d3fe-d56e-dc26-75e9-01e90672f506"
},
{
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
"value": "99999999999"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "institutional"
}
]
},
"subType": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
"code": "inpatient"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/f56391c2-dd54-b378-46ef-87c1643a2ba0"
},
"billablePeriod": {
"start": "2017-01-05T21:41:04+01:00",
"end": "2018-01-05T21:41:04+01:00"
},
"created": "2017-01-05T21:41:04+01:00",
"insurer": {
"display": "Medicaid"
},
"provider": {
"reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
},
"referral": {
"reference": "#referral"
},
"facility": {
"reference": "Location/e111a884-fc5e-3766-9077-c44100ba56e2",
"display": "NEWTON-WELLESLEY HOSPITAL"
},
"claim": {
"reference": "Claim/c145d3fe-d56e-dc26-75e9-01e90672f506"
},
"outcome": "complete",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
},
"role": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code": "primary",
"display": "Primary Care Practitioner"
}
]
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "clmrecvddate"
}
]
},
"timingDate": "2017-01-05"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisReference": {
"reference": "Condition/88bd5ac6-175b-5906-a4ee-6eedd667b0cc"
},
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code": "principal"
}
]
}
]
}
],
"insurance": [
{
"focal": true,
"coverage": {
"display": "Medicaid"
}
}
],
"item": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "185345009",
"display": "Encounter for symptom"
}
],
"text": "Encounter for symptom"
},
"servicedPeriod": {
"start": "2017-01-05T21:26:04+01:00",
"end": "2017-01-05T21:41:04+01:00"
},
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "21",
"display": "Inpatient Hospital"
}
]
},
"encounter": [
{
"reference": "Encounter/97e2c68b-c5e6-02f3-867b-f9f207badd64"
}
]
},
{
"sequence": 2,
"diagnosisSequence": [1],
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "10509002",
"display": "Acute bronchitis (disorder)"
}
],
"text": "Acute bronchitis (disorder)"
},
"servicedPeriod": {
"start": "2017-01-05T21:26:04+01:00",
"end": "2017-01-05T21:41:04+01:00"
},
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "21",
"display": "Inpatient Hospital"
}
]
}
},
{
"sequence": 3,
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "23426006",
"display": "Measurement of respiratory function (procedure)"
}
],
"text": "Measurement of respiratory function (procedure)"
},
"servicedPeriod": {
"start": "2017-01-05T21:26:04+01:00",
"end": "2017-01-05T21:41:04+01:00"
},
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "21",
"display": "Inpatient Hospital"
}
]
},
"net": {
"value": 146.42,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
"display": "Line Beneficiary Coinsurance Amount"
}
]
},
"amount": {
"value": 29.284,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display": "Line Provider Payment Amount"
}
]
},
"amount": {
"value": 117.136,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display": "Line Submitted Charge Amount"
}
]
},
"amount": {
"value": 146.42,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display": "Line Allowed Charge Amount"
}
]
},
"amount": {
"value": 146.42,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display": "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display": "Line Processing Indicator Code"
}
]
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "Submitted Amount"
},
"amount": {
"value": 77.49,
"currency": "USD"
}
}
],
"payment": {
"amount": {
"value": 117.136,
"currency": "USD"
}
}
}