LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="CDMExplanationOfBenefitProfessionalInstance"/>
<meta>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id">
<valueString value="tenant7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzz"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id">
<valueString value="7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessMedicalCenter"/>
<value value="7209_07869_e00080779_3938586_2516181"/>
</valueIdentifier>
</extension>
<source value="http://acme-health.com/WellnessMedicalCenter"/>
<profile
value="http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-explanation-of-benefit"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-eob-identifier"/>
<value value="000000000000000000019721078"/>
<assigner>
<display value="Acme Health - Wellness Medical Center"/>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="MedicalClaimType"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<created value="2017-07-25T17:31:00-05:00"/>
<insurer>
<type value="Organization"/>
<identifier>
<system value="http://acme-health.com/payer1/payer"/>
<value value="Payer1"/>
</identifier>
</insurer>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<outcome value="complete"/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="servicing"/>
</coding>
</role>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="network-provider-indicator"/>
</coding>
</code>
<valueString value="Y"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="Z00.00"/>
<display
value="Encntr for general adult medical exam w/o abnormal findings"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="discharge"/>
</coding>
</type>
</diagnosis>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/PrimaryPayerExample"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system value="https://oidref.com/2.16.840.1.113883.6.285"/>
<code value="G0438"/>
</coding>
<text
value="Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit"/>
</productOrService>
<servicedPeriod>
<start value="2017-06-20"/>
<end value="2017-06-20"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
<display value="Office"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-place-of-service"/>
<code value="LocalPlcOfService"/>
</coding>
</locationCodeableConcept>
<quantity>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service">
<valueQuantity>
<value value="1"/>
</valueQuantity>
</extension>
<value value="1"/>
</quantity>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="coinsurance"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="25"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="deductible"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="third-party"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="allowed"/>
</coding>
</category>
<amount>
<value value="125"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="165"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="net-payment"/>
</coding>
</category>
<amount>
<value value="100"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="discount"/>
</coding>
</category>
<amount>
<value value="40"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator"/>
<code value="in-network"/>
</coding>
</category>
</adjudication>
<payment>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
<code value="complete"/>
</coding>
</type>
<date value="2017-07-20"/>
<amount>
<value value="100"/>
</amount>
</payment>
</ExplanationOfBenefit>
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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