{

"resourceType": "ExplanationOfBenefit",
"id": "EB3500",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
    "value": "987654321"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "oral"
    }
  ]
},
"use": "claim",
"patient": {
  "reference": "Patient/pat1"
},
"created": "2014-08-16",
"enterer": {
  "reference": "Practitioner/1"
},
"insurer": {
  "reference": "Organization/3"
},
"provider": {
  "reference": "Practitioner/1"
},
"payee": {
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payeetype",
        "code": "provider"
      }
    ]
  },
  "party": {
    "reference": "Organization/2"
  }
},
"facility": {
  "reference": "Location/1"
},
"claim": {
  "reference": "Claim/100150"
},
"claimResponse": {
  "reference": "ClaimResponse/R3500"
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"careTeam": [
  {
    "sequence": 1,
    "provider": {
      "reference": "Practitioner/example"
    }
  }
],
"insurance": [
  {
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  }
],
"item": [
  {
    "sequence": 1,
    "careTeamSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
          "code": "1205"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 135.57,
      "currency": "USD"
    },
    "net": {
      "value": 135.57,
      "currency": "USD"
    },
    "udi": [
      {
        "reference": "Device/example"
      }
    ],
    "encounter": [
      {
        "reference": "Encounter/example"
      }
    ],
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 120.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 0.8
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 96.0,
          "currency": "USD"
        }
      }
    ]
  },
  {
    "sequence": 2,
    "careTeamSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "code": "group"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "net": {
      "value": 200.0,
      "currency": "USD"
    },
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 180.0,
          "currency": "USD"
        }
      }
    ],
    "detail": [
      {
        "sequence": 1,
        "productOrService": {
          "coding": [
            {
              "code": "group"
            }
          ]
        },
        "net": {
          "value": 200.0,
          "currency": "USD"
        },
        "udi": [
          {
            "reference": "Device/example"
          }
        ],
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 180.0,
              "currency": "USD"
            }
          }
        ],
        "subDetail": [
          {
            "sequence": 1,
            "productOrService": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/ex-USCLS",
                  "code": "1205"
                }
              ]
            },
            "unitPrice": {
              "value": 200.0,
              "currency": "USD"
            },
            "net": {
              "value": 200.0,
              "currency": "USD"
            },
            "udi": [
              {
                "reference": "Device/example"
              }
            ],
            "adjudication": [
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligible"
                    }
                  ]
                },
                "amount": {
                  "value": 200.0,
                  "currency": "USD"
                }
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligpercent"
                    }
                  ]
                },
                "value": 0.9
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "benefit"
                    }
                  ]
                },
                "amount": {
                  "value": 180.0,
                  "currency": "USD"
                }
              }
            ]
          }
        ]
      }
    ]
  }
],
"total": [
  {
    "category": {
      "coding": [
        {
          "code": "submitted"
        }
      ]
    },
    "amount": {
      "value": 135.57,
      "currency": "USD"
    }
  },
  {
    "category": {
      "coding": [
        {
          "code": "benefit"
        }
      ]
    },
    "amount": {
      "value": 96.0,
      "currency": "USD"
    }
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}