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Source1

{
  "resourceType": "ExplanationOfBenefit",
  "id": "PCT-AEOB-Summary-1",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "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"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
        "code": "estimate-summary",
        "display": "Estimate Summary"
      }
    ]
  },
  "use": "predetermination",
  "patient": {
    "reference": "Patient/patient1001"
  },
  "billablePeriod": {
    "start": "2022-01-01",
    "end": "2022-01-01"
  },
  "created": "2021-10-12",
  "insurer": {
    "reference": "Organization/org1001"
  },
  "provider": {
    "extension": [
      {
        "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
        "valueCode": "not-applicable"
      }
    ]
  },
  "outcome": "complete",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage1001"
      }
    }
  ],
  "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": "2022-01-01"
  },
  "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"
          }
        }
      ]
    }
  ]
}