Midtown Imaging Center

claim eob-2026-burn-4 · 1 line

Line 1

Claim ID: eob-2026-burn-4
Provider: Midtown Imaging Center
Service date: 2026-04-11
Claim type: professional
Code system: cpt
Service code: 99214
Service: Skin biopsy, tangential
Billed: $663.66
Allowed: $663.66
Plan paid: $330.93
Deductible: $250.00
Copay: $0.00
Coinsurance: $82.73
Noncovered: $0.00
Your share: $332.73
Adjudication: paid
Denial code: not set
Denial reason: not set
Prior auth reference: not set

Raw FHIR ExplanationOfBenefit

{
  "resourceType": "ExplanationOfBenefit",
  "id": "eob-2026-burn-4",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ],
    "text": "professional"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-1"
  },
  "billablePeriod": {
    "start": "2026-04-11",
    "end": "2026-04-11"
  },
  "created": "2026-04-11",
  "insurer": {
    "display": "Acme Health Plan"
  },
  "provider": {
    "display": "Midtown Imaging Center"
  },
  "outcome": "complete",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "99214",
            "display": "Skin biopsy, tangential"
          }
        ]
      },
      "servicedDate": "2026-04-11",
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 663.6600000000001,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 330.93,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "deductible"
              }
            ]
          },
          "amount": {
            "value": 250,
            "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": 82.73,
            "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": 663.6600000000001,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 330.93,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "amount": {
      "value": 330.93,
      "currency": "USD"
    }
  }
}