FHIR IG analytics| Package | hl7.fhir.us.davinci-pct |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-PCT-AEOB-1.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit PCT-AEOB-1
Profile: PCT Advanced EOB
Service Description: Example service
In Network Provider Options Link: http://example.org/out-of-network.html
identifier: Unique Claim Identifier/?ngen-9?
status: Active
type: Institutional
use: Predetermination
patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
created: 2021-10-12
insurer: Organization Umbrella Insurance Company
provider: Organization Boston Radiology Center
priority: Normal
claim: Identifier: http://example.com/identifiers/bundle/59688475-2324-3242-23473847
outcome: Processing Complete
| Focal | Coverage |
| true | Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01 |
item
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
serviced: 2022-01-01
Nets
Value Currency 200 United States dollar Adjudications
Extension Category Medical Management
| Extension | Category |
| Medical Management | |
| Submitted Amount | |
| Member Liability |
total
category: Submitted Amount
Amounts
Value Currency 200 United States dollar
total
category: Member liability
Amounts
Value Currency 20 United States dollar
total
category: Eligible Amount
Amounts
Value Currency 190 United States dollar
| Extension | Text |
| processNote disclaimer text |
benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care
unit: Individual
term: Annual
Financials
Extension Type Allowed[x] Used[x] Allowed $1.00 (USD) $1.00 (USD)
FHIR
FHIRsmith{
"resourceType": "ExplanationOfBenefit",
"id": "PCT-AEOB-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
]
},
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
"valueReference": {
"reference": "Bundle/PCT-GFE-Bundle-Inst-1"
}
},
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString": "Example service"
},
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl": "http://example.org/out-of-network.html"
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "UCID"
}
]
}
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "institutional",
"display": "Institutional"
}
]
},
"use": "predetermination",
"patient": {
"reference": "Patient/patient1001"
},
"created": "2021-10-12",
"insurer": {
"reference": "Organization/org1001"
},
"provider": {
"reference": "Organization/org1002"
},
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal"
}
]
},
"claim": {
"identifier": {
"system": "http://example.com/identifiers/bundle",
"value": "59688475-2324-3242-23473847"
}
},
"outcome": "complete",
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/coverage1001"
}
}
],
"item": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0611",
"display": "Magnetic Resonance Technology (MRT) - Brain/brain stem"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "70551",
"display": "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "70551",
"display": "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
}
],
"servicedDate": "2022-01-01",
"net": {
"value": 200,
"currency": "USD"
},
"adjudication": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/medical-management-type",
"code": "concurrent-review",
"display": "Concurrent Review"
}
]
}
}
],
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code": "medicalmanagement",
"display": "Medical Management"
}
]
}
}
]
}
],
"adjudication": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/medical-management-type",
"code": "concurrent-review",
"display": "Concurrent Review"
}
]
}
}
],
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code": "medicalmanagement",
"display": "Medical Management"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted",
"display": "Submitted Amount"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code": "memberliability",
"display": "Member Liability"
}
]
}
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
]
},
"amount": {
"value": 200,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code": "memberliability",
"display": "Member liability"
}
]
},
"amount": {
"value": 20,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
]
},
"amount": {
"value": 190,
"currency": "USD"
}
}
],
"processNote": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
"code": "disclaimer",
"display": "Disclaimer"
}
]
}
}
],
"text": "processNote disclaimer text"
}
],
"benefitPeriod": {
"start": "2022-01-01",
"end": "2023-01-01"
},
"benefitBalance": [
{
"category": {
"coding": [
{
"system": "https://x12.org/codes/service-type-codes",
"code": "1",
"display": "Medical Care"
}
],
"text": "Medical Care"
},
"unit": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
"code": "individual"
}
]
},
"term": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/benefit-term",
"code": "annual"
}
]
},
"financial": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
"valueMoney": {
"value": 0,
"currency": "USD"
}
}
],
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code": "allowed"
}
]
},
"allowedMoney": {
"value": 1,
"currency": "USD"
},
"usedMoney": {
"value": 1,
"currency": "USD"
}
}
]
}
]
}