JSON Format: ExplanationOfBenefit-ad9ce909-fe25-44b7-8369-d104be90b146
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Validation results for ExplanationOfBenefit/ad9ce909-fe25-44b7-8369-d104be90b146
| Level | Type | Location | Message | |
| warning | code-invalid | ExplanationOfBenefit/ad9ce909-fe25-44b7-8369-d104be90b146: 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" : "ad9ce909-fe25-44b7-8369-d104be90b146",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: ad9ce909-fe25-44b7-8369-d104be90b146</p><p><b>contained</b>: , </p><p><b>identifier</b>: 414f2bd3-cbf3-4952-bd0f-fb48cf962af2, 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>: Mar 3, 1992, 3:31:44 PM --> Mar 3, 1993, 3:31:44 PM</p><p><b>created</b>: Mar 3, 1992, 3:31:44 PM</p><p><b>insurer</b>: Cigna Health</p><p><b>provider</b>: <a href=\"Practitioner-0000016d-235f-39b3-0000-0000000051f4.html\">Generated Summary: id: 0000016d-235f-39b3-0000-0000000051f4; 20980; active; Marica887 Bode78 ; Marica887.Bode78@example.com(WORK); gender: female</a></p><p><b>referral</b>: unknown resource contained</p><p><b>facility</b>: <a href=\"Location-1e84a992-8d6e-41d1-af95-4316a6a139fb.html\">PCP31369. Generated Summary: id: 1e84a992-8d6e-41d1-af95-4316a6a139fb; status: active; name: PCP31369; ph: 781-934-2597</a></p><p><b>claim</b>: <a href=\"Claim-414f2bd3-cbf3-4952-bd0f-fb48cf962af2.html\">Generated Summary: id: 414f2bd3-cbf3-4952-bd0f-fb48cf962af2; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span>; use: claim; billablePeriod: Mar 3, 1992, 3:16:44 PM --> Mar 3, 1992, 3:31:44 PM; created: Mar 3, 1992, 3:31:44 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-39b3-0000-0000000051f4"
},
"performer" : [
{
"reference" : "Practitioner/0000016d-235f-39b3-0000-0000000051f4"
}
]
},
{
"resourceType" : "Coverage",
"id" : "coverage",
"status" : "active",
"type" : {
"text" : "Cigna Health"
},
"beneficiary" : {
"reference" : "Patient/3ab28624-a549-4cb9-a32e-99e3c2c41129"
},
"payor" : [
{
"display" : "Cigna Health"
}
]
}
],
"identifier" : [
{
"system" : "https://bluebutton.cms.gov/resources/variables/clm_id",
"value" : "414f2bd3-cbf3-4952-bd0f-fb48cf962af2"
},
{
"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" : "1992-03-03T15:31:44-08:00",
"end" : "1993-03-03T15:31:44-08:00"
},
"created" : "1992-03-03T15:31:44-08:00",
"insurer" : {
"display" : "Cigna Health"
},
"provider" : {
"reference" : "Practitioner/0000016d-235f-39b3-0000-0000000051f4"
},
"referral" : {
"reference" : "#referral"
},
"facility" : {
"reference" : "Location/1e84a992-8d6e-41d1-af95-4316a6a139fb",
"display" : "PCP31369"
},
"claim" : {
"reference" : "Claim/414f2bd3-cbf3-4952-bd0f-fb48cf962af2"
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/0000016d-235f-39b3-0000-0000000051f4"
},
"role" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code" : "primary",
"display" : "Primary Care Practitioner"
}
]
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisReference" : {
"reference" : "Condition/c427b996-7a5b-456e-8911-8d1479853145"
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "#coverage",
"display" : "Cigna Health"
}
}
],
"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" : "162673000",
"display" : "General examination of patient (procedure)"
}
],
"text" : "General examination of patient (procedure)"
},
"servicedPeriod" : {
"start" : "1992-03-03T15:16:44-08:00",
"end" : "1992-03-03T15:31:44-08:00"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "19",
"display" : "Off Campus-Outpatient Hospital"
}
]
},
"encounter" : [
{
"reference" : "Encounter/812b9437-26c9-4ee8-9c55-2a369be34708"
}
]
},
{
"sequence" : 2,
"diagnosisSequence" : [
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" : "237602007",
"display" : "Metabolic syndrome X (disorder)"
}
],
"text" : "Metabolic syndrome X (disorder)"
},
"servicedPeriod" : {
"start" : "1992-03-03T15:16:44-08:00",
"end" : "1992-03-03T15:31:44-08:00"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "19",
"display" : "Off Campus-Outpatient Hospital"
}
]
}
}
],
"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" : 0.0,
"currency" : "USD"
}
}
}
