fhir-react/src/fixtures/stu3/resources/explanationOfBenefit/example1.json

React component library for displaying FHIR Resources

{
  "claim": {
    "reference": "Claim/100150"
  },
  "facility": {
    "reference": "Location/1"
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
  },
  "claimResponse": {
    "reference": "ClaimResponse/R3500"
  },
  "insurance": {
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  },
  "totalCost": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 135.57
  },
  "item": [
    {
      "service": {
        "coding": [
          {
            "code": "1200",
            "system": "http://hl7.org/fhir/service-uscls"
          }
        ]
      },
      "sequence": 1,
      "servicedDate": "2014-08-16",
      "careTeamLinkId": [
        1
      ],
      "net": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 120
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 0.8
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 96
          }
        }
      ],
      "unitPrice": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      },
      "encounter": [
        {
          "reference": "Encounter/example"
        }
      ]
    }
  ],
  "enterer": {
    "reference": "Practitioner/1"
  },
  "id": "EB3500",
  "provider": {
    "reference": "Practitioner/1"
  },
  "type": {
    "coding": [
      {
        "code": "oral",
        "system": "http://hl7.org/fhir/ex-claimtype"
      }
    ]
  },
  "status": "active",
  "patient": {
    "reference": "Patient/pat1"
  },
  "disposition": "Claim settled as per contract.",
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
      "value": "987654321"
    }
  ],
  "created": "2014-08-16",
  "resourceType": "ExplanationOfBenefit",
  "totalBenefit": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 96
  },
  "payee": {
    "resourceType": {
      "coding": [
        {
          "code": "organization",
          "system": "http://hl7.org/fhir/resource-type-link"
        }
      ]
    },
    "party": {
      "reference": "Organization/2"
    },
    "type": {
      "coding": [
        {
          "code": "provider",
          "system": "http://hl7.org/fhir/payeetype"
        }
      ]
    }
  },
  "careTeam": [
    {
      "provider": {
        "reference": "Practitioner/example"
      },
      "sequence": 1
    }
  ],
  "organization": {
    "reference": "Organization/2"
  },
  "outcome": {
    "coding": [
      {
        "code": "complete",
        "system": "http://hl7.org/fhir/remittance-outcome"
      }
    ]
  }
}