LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
{
"resourceType" : "ExplanationOfBenefit",
"id" : "CDMExplanationOfBenefitProfessionalInstance",
"meta" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id",
"valueString" : "tenant7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id",
"valueString" : "rgVCJnQBxvghkKTI8Hzz"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name",
"valueString" : "TREX"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id",
"valueString" : "7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id",
"valueIdentifier" : {
"system" : "http://acme-health.com/WellnessMedicalCenter",
"value" : "7209_07869_e00080779_3938586_2516181"
}
}
],
"source" : "http://acme-health.com/WellnessMedicalCenter",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-explanation-of-benefit"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"CDMExplanationOfBenefitProfessionalInstance\"> </a></p><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\">Resource ExplanationOfBenefit \"CDMExplanationOfBenefitProfessionalInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessMedicalCenter!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-explanation-of-benefit.html\">CDM Explanation of Benefit</a></p></div><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL)</p><p><b>status</b>: active</p><p><b>type</b>: MedicalClaimType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-claim-type#MedicalClaimType)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-CDMPatientInstance.html\">Patient/CDMPatientInstance</a> \" MCLASTNAME\"</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>insurer</b>: <span></span></p><p><b>provider</b>: <a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</p><p><b>outcome</b>: complete</p><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</td><td>Servicing provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#servicing)</span></td></tr></table><h3>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1</td><td>Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></td><td>Network provider indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#network-provider-indicator)</span></td><td>Y</td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td>Encntr for general adult medical exam w/o abnormal findings <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#Z00.00)</span></td><td>Discharge Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#discharge)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-PrimaryPayerExample.html\">Coverage/PrimaryPayerExample</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (2.16.840.1.113883.6.285#G0438)</span></p><p><b>serviced</b>: 2017-06-20 --> 2017-06-20</p><p><b>location</b>: Office <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#11; local-place-of-service#LocalPlcOfService)</span></p><p><b>quantity</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#coinsurance)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Copayment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#copay)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>25</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Deductible Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#deductible)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Third Party Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#third-party)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Allowed Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#allowed)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>125</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>165</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Net Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#net-payment)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#discount)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>40</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td></tr><tr><td>*</td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-paid-in-network-indicator.html\">Paid In Network Indicator Codes</a>#in-network)</span></td></tr></table><blockquote><p><b>payment</b></p><p><b>type</b>: Complete <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-paymenttype.html\">Example Payment Type Codes</a>#complete)</span></p><p><b>date</b>: 2017-07-20</p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>100</td></tr></table></blockquote></div>"
},
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "SSRI"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-eob-identifier",
"value" : "000000000000000000019721078",
"assigner" : {
"display" : "Acme Health - Wellness Medical Center"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-claim-type",
"code" : "MedicalClaimType"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/CDMPatientInstance"
},
"created" : "2017-07-25T17:31:00-05:00",
"insurer" : {
"type" : "Organization",
"identifier" : {
"system" : "http://acme-health.com/payer1/payer",
"value" : "Payer1"
}
},
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "servicing"
}
]
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "network-provider-indicator"
}
]
},
"valueString" : "Y"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "Z00.00",
"display" : "Encntr for general adult medical exam w/o abnormal findings"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "discharge"
}
]
}
]
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/PrimaryPayerExample"
}
}
],
"item" : [
{
"sequence" : 1,
"careTeamSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "https://oidref.com/2.16.840.1.113883.6.285",
"code" : "G0438"
}
],
"text" : "Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit"
},
"servicedPeriod" : {
"start" : "2017-06-20",
"end" : "2017-06-20"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11",
"display" : "Office"
},
{
"system" : "http://acme-health.com/CodeSystem/local-place-of-service",
"code" : "LocalPlcOfService"
}
]
},
"quantity" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service",
"valueQuantity" : {
"value" : 1
}
}
],
"value" : 1
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "coinsurance"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "copay"
}
]
},
"amount" : {
"value" : 25,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "deductible"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "third-party"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "allowed"
}
]
},
"amount" : {
"value" : 125,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 165,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "net-payment"
}
]
},
"amount" : {
"value" : 100,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "discount"
}
]
},
"amount" : {
"value" : 40,
"currency" : "USD"
}
}
]
}
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator",
"code" : "in-network"
}
]
}
}
],
"payment" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code" : "complete"
}
]
},
"date" : "2017-07-20",
"amount" : {
"value" : 100
}
}
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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