Harborview Surgical Pavilion

claim eob-2026-burn-2 · 1 line

Line 1

Claim ID: eob-2026-burn-2
Provider: Harborview Surgical Pavilion
Service date: 2026-02-25
Claim type: institutional
Code system: cpt
Service code: 70450
Service: CT head/brain without contrast
Billed: $1,115.43
Allowed: $1,115.43
Plan paid: $212.34
Deductible: $850.00
Copay: $0.00
Coinsurance: $53.09
Noncovered: $0.00
Your share: $903.09
Adjudication: paid
Denial code: not set
Denial reason: not set
Prior auth reference: not set

Raw FHIR ExplanationOfBenefit

{
  "resourceType": "ExplanationOfBenefit",
  "id": "eob-2026-burn-2",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "institutional"
      }
    ],
    "text": "institutional"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-1"
  },
  "billablePeriod": {
    "start": "2026-02-25",
    "end": "2026-02-25"
  },
  "created": "2026-02-25",
  "insurer": {
    "display": "Acme Health Plan"
  },
  "provider": {
    "display": "Harborview Surgical Pavilion"
  },
  "outcome": "complete",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "70450",
            "display": "CT head/brain without contrast"
          }
        ]
      },
      "servicedDate": "2026-02-25",
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 1115.43,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 212.34,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "deductible"
              }
            ]
          },
          "amount": {
            "value": 850,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "coinsurance"
              }
            ]
          },
          "amount": {
            "value": 53.09,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "noncovered"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 1115.43,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 212.34,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "amount": {
      "value": 212.34,
      "currency": "USD"
    }
  }
}