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