<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" />
    </meta>
    <language value="en-US" />
    <text>
        <status value="generated" />
        --- We have skipped the narrative for better readability of the resource ---
    </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="Inpatient Institution" />
    </type>
    <use value="claim" />
    <patient>
        <reference value="Patient/Patient1" />
    </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/OrganizationProvider1" />
        <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="1" />
        <category>
            <coding>
                <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
                <code value="billingnetworkcontractingstatus" />
            </coding>
        </category>
        <code>
            <coding>
                <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" />
                <code value="contracted" />
            </coding>
        </code>
    </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>
    <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/Coverage1" />
        </coverage>
    </insurance>
    <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>
    <total>
        <category>
            <coding>
                <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" />
                <code value="innetwork" />
            </coding>
        </category>
        <amount>
            <value value="0" />
            <currency value="USD" />
        </amount>
    </total>
</ExplanationOfBenefit>