{
  "resourceType": "ExplanationOfBenefit",
  "id": "EOBInpatient1",
  "meta": {
    "lastUpdated": "2019-12-12T09:14:11+00:00",
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.0"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<div></div>"
  },
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code": "uc"
          }
        ]
      },
      "system": "https://www.xxxplan.com/fhir/EOBIdentifier",
      "value": "AW123412341234123412341234123412"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "institutional"
      }
    ],
    "text": "Institutional"
  },
  "subType": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
        "code": "inpatient"
      }
    ],
    "text": "Inpatient"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/Patient2"
  },
  "billablePeriod": {
    "start": "2019-01-01",
    "end": "2019-10-31"
  },
  "created": "2019-11-02T00:00:00+00:00",
  "insurer": {
    "reference": "Organization/Payer1",
    "display": "XXX Health Plan"
  },
  "provider": {
    "reference": "Organization/ProviderOrganization1",
    "display": "XXX Health Plan"
  },
  "outcome": "partial",
  "supportingInfo": [
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "admissionperiod"
          }
        ]
      },
      "timingPeriod": {
        "start": "2011-05-23",
        "end": "2011-05-25"
      }
    },
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "clmrecvddate"
          }
        ]
      },
      "timingDate": "2011-05-30"
    },
    {
      "sequence": 4,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "typeofbill"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/TypeOfBill",
            "code": "Dummy"
          }
        ]
      }
    },
    {
      "sequence": 5,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "pointoforigin"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/PointOfOrigin",
            "code": "Dummy"
          }
        ]
      }
    },
    {
      "sequence": 6,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "admtype"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit",
            "code": "Dummy"
          }
        ]
      }
    },
    {
      "sequence": 7,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "discharge-status"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/PatDischargeStatus",
            "code": "11"
          }
        ]
      }
    },
    {
      "sequence": 8,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "medicalrecordnumber"
          }
        ]
      },
      "valueString": "1234-234-1243-12345678901m"
    },
    {
      "sequence": 9,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "patientaccountnumber"
          }
        ]
      },
      "valueString": "1234-234-1243-12345678901a"
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "S06.0X1A"
          }
        ]
      },
      "type": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code": "principal"
            }
          ]
        }
      ]
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/Coverage3"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "revenue": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code": "Dummy"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/data-absent-reason",
            "code": "not-applicable",
            "display": "Not Applicable"
          }
        ]
      },
      "servicedDate": "2019-11-02"
    }
  ],
  "adjudication": [
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "benefitpaymentstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "billingnetworkstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidtoprovider"
          }
        ],
        "text": "Payment Amount"
      },
      "amount": {
        "value": 620,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 2650,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidbypatient"
          }
        ],
        "text": "Patient Pay Amount"
      },
      "amount": {
        "value": 0,
        "currency": "USD"
      }
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidtoprovider"
          }
        ],
        "text": "Payment Amount"
      },
      "amount": {
        "value": 620,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 2650,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidbypatient"
          }
        ],
        "text": "Patient Pay Amount"
      },
      "amount": {
        "value": 0,
        "currency": "USD"
      }
    }
  ]
}