LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "CDMExplanationOfBenefitProfessionalInstance"
Information Source: http://acme-health.com/WellnessMedicalCenter!
Profile: CDM Explanation of Benefit
identifier: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL)
status: active
type: MedicalClaimType (local-claim-type#MedicalClaimType)
use: claim
patient: Patient/CDMPatientInstance " MCLASTNAME"
created: 2017-07-25 05:31:00-0500
insurer:
provider: Practitioner/DrKelly " KELLY"
outcome: complete
| - | Sequence | Provider | Role |
| * | 1 | Practitioner/DrKelly " KELLY" | Servicing provider (Claim Care Team Role Codes#servicing) |
| - | Sequence | Category | Code | Value[x] |
| * | 1 | Information (Claim Information Category Codes#info) | Network provider indicator (Claim Supporting Info Type Codes#network-provider-indicator) | Y |
| - | Sequence | Diagnosis[x] | Type |
| * | 1 | Encntr for general adult medical exam w/o abnormal findings (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#Z00.00) | Discharge Diagnosis (Example Diagnosis Type Codes#discharge) |
| - | Focal | Coverage |
| * | true | Coverage/PrimaryPayerExample |
item
sequence: 1
careTeamSequence: 1
productOrService: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (2.16.840.1.113883.6.285#G0438)
serviced: 2017-06-20 --> 2017-06-20
location: Office (CMS Place of Service Codes (POS)#11; local-place-of-service#LocalPlcOfService)
quantity: 1
adjudication
category: Coinsurance (Adjudication Category Codes#coinsurance)
Amounts
- Value Currency * 0 USD adjudication
category: Copayment (Adjudication Category Codes#copay)
Amounts
- Value Currency * 25 USD adjudication
category: Deductible Amount (Adjudication Category Codes#deductible)
Amounts
- Value Currency * 0 USD adjudication
category: Third Party Amount (Adjudication Category Codes#third-party)
Amounts
- Value Currency * 0 USD adjudication
category: Allowed Amount (Adjudication Category Codes#allowed)
Amounts
- Value Currency * 125 USD adjudication
category: Submitted (Adjudication Category Codes#submitted)
Amounts
- Value Currency * 165 USD adjudication
category: Net Payment (Adjudication Category Codes#net-payment)
Amounts
- Value Currency * 100 USD adjudication
category: Discount Amount (Adjudication Category Codes#discount)
Amounts
- Value Currency * 40 USD
| - | Category |
| * | In Network (Paid In Network Indicator Codes#in-network) |
payment
type: Complete (Example Payment Type Codes#complete)
date: 2017-07-20
Amounts
- Value * 100