{

"resourceType": "ExplanationOfBenefit",
"id": "EB3501",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
    "value": "error-1"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "oral"
    }
  ]
},
"subType": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
      "code": "emergency"
    }
  ]
},
"use": "claim",
"patient": {
  "reference": "Patient/pat1"
},
"billablePeriod": {
  "start": "2014-02-01",
  "end": "2014-03-01"
},
"created": "2014-08-16",
"enterer": {
  "reference": "Practitioner/1"
},
"insurer": {
  "reference": "Organization/2"
},
"provider": {
  "reference": "Organization/2"
},
"related": [
  {
    "reference": {
      "system": "http://www.BenefitsInc.com/case-number",
      "value": "23-56Tu-XX-47-20150M14"
    }
  }
],
"prescription": {
  "reference": "MedicationRequest/medrx002"
},
"originalPrescription": {
  "reference": "MedicationRequest/medrx0301"
},
"facility": {
  "reference": "Location/1"
},
"claim": {
  "reference": "Claim/100150"
},
"claimResponse": {
  "reference": "ClaimResponse/R3500"
},
"outcome": "error",
"disposition": "Could not process.",
"supportingInfo": [
  {
    "sequence": 1,
    "category": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
          "code": "employmentimpacted"
        }
      ]
    },
    "timingPeriod": {
      "start": "2014-02-14",
      "end": "2014-02-28"
    }
  },
  {
    "sequence": 2,
    "category": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
          "code": "hospitalized"
        }
      ]
    },
    "timingPeriod": {
      "start": "2014-02-14",
      "end": "2014-02-16"
    }
  }
],
"procedure": [
  {
    "sequence": 1,
    "date": "2014-02-14",
    "procedureCodeableConcept": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/sid/ex-icd-10-procedures",
          "code": "123001"
        }
      ]
    },
    "udi": [
      {
        "reference": "Device/example"
      }
    ]
  }
],
"precedence": 2,
"insurance": [
  {
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  }
],
"accident": {
  "date": "2014-02-14",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "SPT"
      }
    ]
  },
  "locationReference": {
    "reference": "Location/ph"
  }
},
"total": [
  {
    "category": {
      "coding": [
        {
          "code": "submitted"
        }
      ]
    },
    "amount": {
      "value": 2478.57,
      "currency": "USD"
    }
  },
  {
    "category": {
      "coding": [
        {
          "code": "benefit"
        }
      ]
    },
    "amount": {
      "value": 0.0,
      "currency": "USD"
    }
  }
],
"formCode": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/forms-codes",
      "code": "2"
    }
  ]
},
"processNote": [
  {
    "number": 1,
    "type": "display",
    "text": "Invalid claim",
    "language": {
      "coding": [
        {
          "system": "urn:ietf:bcp:47",
          "code": "en-CA"
        }
      ]
    }
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}