JSON Format: ExplanationOfBenefit-0d532d83-1615-475f-9694-d2d97f331d98
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Validation results for ExplanationOfBenefit/0d532d83-1615-475f-9694-d2d97f331d98
| Level | Type | Location | Message | |
| warning | code-invalid | ExplanationOfBenefit/0d532d83-1615-475f-9694-d2d97f331d98: ExplanationOfBenefit.careTeam[0].role.coding[0] | Display Name for http://terminology.hl7.org/CodeSystem/claimcareteamrole#primary should be one of 'Primary provider' |
{
"resourceType" : "ExplanationOfBenefit",
"id" : "0d532d83-1615-475f-9694-d2d97f331d98",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 0d532d83-1615-475f-9694-d2d97f331d98</p><p><b>contained</b>: , </p><p><b>identifier</b>: c3c89e4c-01b3-4bc2-88fd-bdb109b63dfb, 99999999999</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'institutional' = 'Institutional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-3ab28624-a549-4cb9-a32e-99e3c2c41129.html\">Generated Summary: id: 3ab28624-a549-4cb9-a32e-99e3c2c41129; 52fb90a7-9e4f-4140-8c3c-c8afbbb3fbf9, Medical Record Number = 52fb90a7-9e4f-4140-8c3c-c8afbbb3fbf9, Social Security Number = 999-96-5270, Driver's License = S99943652, Passport Number = X37948891X; Jose871 Cruickshank494 (OFFICIAL); ph: 555-170-1696(HOME); gender: male; birthDate: Feb 20, 1940; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus M}\">M</span>; </a></p><p><b>billablePeriod</b>: May 1, 2018, 4:46:44 PM --> May 1, 2019, 4:46:44 PM</p><p><b>created</b>: May 1, 2018, 4:46:44 PM</p><p><b>insurer</b>: Medicare</p><p><b>provider</b>: <a href=\"Practitioner-0000016d-235f-39b3-0000-00000000032a.html\">Generated Summary: id: 0000016d-235f-39b3-0000-00000000032a; 810; active; Sergio619 Armijo730 ; Sergio619.Armijo730@example.com(WORK); gender: male</a></p><p><b>referral</b>: unknown resource contained</p><p><b>facility</b>: <a href=\"Location-7653e0ab-0566-4083-95d8-c695e4735e53.html\">Quincy Outpatient Clinic. Generated Summary: id: 7653e0ab-0566-4083-95d8-c695e4735e53; status: active; name: Quincy Outpatient Clinic; ph: 800-865-3384</a></p><p><b>claim</b>: <a href=\"Claim-c3c89e4c-01b3-4bc2-88fd-bdb109b63dfb.html\">Generated Summary: id: c3c89e4c-01b3-4bc2-88fd-bdb109b63dfb; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span>; use: claim; billablePeriod: May 1, 2018, 4:16:44 PM --> May 1, 2018, 4:46:44 PM; created: May 1, 2018, 4:46:44 PM; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span>; </a></p><p><b style=\"color: maroon\">Exception generating Narrative: type org.hl7.fhir.r5.model.Money not handled yet</b></p></div>"
},
"contained" : [
{
"resourceType" : "ServiceRequest",
"id" : "referral",
"status" : "completed",
"intent" : "order",
"subject" : {
"reference" : "Patient/3ab28624-a549-4cb9-a32e-99e3c2c41129"
},
"requester" : {
"reference" : "Practitioner/0000016d-235f-39b3-0000-00000000032a"
},
"performer" : [
{
"reference" : "Practitioner/0000016d-235f-39b3-0000-00000000032a"
}
]
},
{
"resourceType" : "Coverage",
"id" : "coverage",
"status" : "active",
"type" : {
"text" : "Medicare"
},
"beneficiary" : {
"reference" : "Patient/3ab28624-a549-4cb9-a32e-99e3c2c41129"
},
"payor" : [
{
"display" : "Medicare"
}
]
}
],
"identifier" : [
{
"system" : "https://bluebutton.cms.gov/resources/variables/clm_id",
"value" : "c3c89e4c-01b3-4bc2-88fd-bdb109b63dfb"
},
{
"system" : "https://bluebutton.cms.gov/resources/identifier/claim-group",
"value" : "99999999999"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/3ab28624-a549-4cb9-a32e-99e3c2c41129"
},
"billablePeriod" : {
"start" : "2018-05-01T16:46:44-07:00",
"end" : "2019-05-01T16:46:44-07:00"
},
"created" : "2018-05-01T16:46:44-07:00",
"insurer" : {
"display" : "Medicare"
},
"provider" : {
"reference" : "Practitioner/0000016d-235f-39b3-0000-00000000032a"
},
"referral" : {
"reference" : "#referral"
},
"facility" : {
"reference" : "Location/7653e0ab-0566-4083-95d8-c695e4735e53",
"display" : "Quincy Outpatient Clinic"
},
"claim" : {
"reference" : "Claim/c3c89e4c-01b3-4bc2-88fd-bdb109b63dfb"
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/0000016d-235f-39b3-0000-00000000032a"
},
"role" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code" : "primary",
"display" : "Primary Care Practitioner"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "#coverage",
"display" : "Medicare"
}
}
],
"item" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code" : "1",
"display" : "Medical care"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "185349003",
"display" : "Encounter for check up (procedure)"
}
],
"text" : "Encounter for check up (procedure)"
},
"servicedPeriod" : {
"start" : "2018-05-01T16:16:44-07:00",
"end" : "2018-05-01T16:46:44-07:00"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "21",
"display" : "Inpatient Hospital"
}
]
},
"encounter" : [
{
"reference" : "Encounter/990edceb-afcd-4302-8124-5993a98ff4fc"
}
]
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code" : "1",
"display" : "Medical care"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "180325003",
"display" : "Electrical cardioversion"
}
],
"text" : "Electrical cardioversion"
},
"servicedPeriod" : {
"start" : "2018-05-01T16:16:44-07:00",
"end" : "2018-05-01T16:46:44-07:00"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "21",
"display" : "Inpatient Hospital"
}
]
},
"net" : {
"value" : 33873.12,
"currency" : "USD"
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
"display" : "Line Beneficiary Coinsurance Amount"
}
]
},
"amount" : {
"value" : 6774.624000000001,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display" : "Line Provider Payment Amount"
}
]
},
"amount" : {
"value" : 27098.496000000003,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display" : "Line Submitted Charge Amount"
}
]
},
"amount" : {
"value" : 33873.12,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display" : "Line Allowed Charge Amount"
}
]
},
"amount" : {
"value" : 33873.12,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display" : "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code" : "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display" : "Line Processing Indicator Code"
}
]
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 129.16,
"currency" : "USD"
}
}
],
"payment" : {
"amount" : {
"value" : 27098.496000000003,
"currency" : "USD"
}
}
}
