Operation | update ExplanationOfBenefit |
Method | PUT |
Path | https://blaze.life.uni-leipzig.de/fhir/ExplanationOfBenefit/C72AWWEQSIXQRF6I |
Resource | ExplanationOfBenefit | Id | C72AWWEQSIXQRF6I | | |
<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="C72AWWEQSIXQRF6I"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ExplanationOfBenefit</div>
</text>
<identifier>
<system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>
<value value="wqf3Df-N1I2kTTcyJCL"/>
</identifier>
<status value="cancelled"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="oral"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/C72AWVYEFTZFGBOE"/>
</patient>
<created value="2014-08-16"/>
<enterer>
<reference value="Practitioner/C72AWV2BQ7WXN3L6"/>
</enterer>
<insurer>
<reference value="Organization/C72AWV4AJY34NTDD"/>
</insurer>
<provider>
<reference value="Practitioner/C72AWV2BQ7WXN3L6"/>
</provider>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
<party>
<reference value="Organization/C72AWV6FSITUD232"/>
</party>
</payee>
<facility>
<reference value="Location/C72AWWAFFVGHGGLW"/>
</facility>
<outcome value="complete"/>
<disposition value="Claim settled as per contract."/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/C72AWV2BQ7WXN3L6"/>
</provider>
</careTeam>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/C72AWWCDZXCZQX5O"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
<code value="1205"/>
</coding>
</productOrService>
<servicedDate value="2014-08-16"/>
<unitPrice>
<value value="135.57"/>
<currency value="USD"/>
</unitPrice>
<net>
<value value="135.57"/>
<currency value="USD"/>
</net>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="120.00"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligpercent"/>
</coding>
</category>
<value value="0.80"/>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="96.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<item>
<sequence value="2"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
<code value="21211"/>
</coding>
</productOrService>
<servicedDate value="2014-08-16"/>
<net>
<value value="200.00"/>
<currency value="USD"/>
</net>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="180.00"/>
<currency value="USD"/>
</amount>
</adjudication>
<detail>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
<code value="21211"/>
</coding>
</productOrService>
<net>
<value value="200.00"/>
<currency value="USD"/>
</net>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="180.00"/>
<currency value="USD"/>
</amount>
</adjudication>
<subDetail>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
<code value="1205"/>
</coding>
</productOrService>
<unitPrice>
<value value="200.00"/>
<currency value="USD"/>
</unitPrice>
<net>
<value value="200.00"/>
<currency value="USD"/>
</net>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="200.00"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligpercent"/>
</coding>
</category>
<value value="0.90"/>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="180.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</subDetail>
</detail>
</item>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="180.00"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="96.00"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>