CMS — Centers for Medicare & Medicaid Services · Example Payload

Cms Gov Explanation Of Benefit Example

HealthcareMedicareMedicaidFHIRBulk DataOpen DataGovernmentFederalClaimsInsuranceACAMarketplaceQuality

Cms Gov Explanation Of Benefit Example is an example object payload from CMS — Centers for Medicare & Medicaid Services, with 16 top-level fields. It illustrates the shape of data this provider's APIs accept or return.

Top-level fields

resourceTypeidmetastatustypeusepatientbillablePeriodcreatedinsurerprovideroutcomediagnosisitemtotalpayment

Example Payload

{
  "resourceType": "ExplanationOfBenefit",
  "id": "carrier-10000932623",
  "meta": {
    "lastUpdated": "2026-04-30T12:34:56.000-05:00",
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician"
    ]
  },
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "https://bluebutton.cms.gov/resources/codesystem/eob-type",
        "code": "CARRIER",
        "display": "Carrier"
      }
    ]
  },
  "use": "claim",
  "patient": { "reference": "Patient/-20140000008325" },
  "billablePeriod": {
    "start": "2026-03-12",
    "end": "2026-03-12"
  },
  "created": "2026-04-15T00:00:00-05:00",
  "insurer": { "reference": "Organization/CMS" },
  "provider": { "reference": "Practitioner/1234567890" },
  "outcome": "complete",
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          { "system": "http://hl7.org/fhir/sid/icd-10-cm", "code": "I10", "display": "Essential (primary) hypertension" }
        ]
      },
      "type": [
        { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] }
      ]
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          { "system": "https://bluebutton.cms.gov/resources/codesystem/hcpcs", "code": "99213", "display": "Office visit, established patient" }
        ]
      },
      "servicedDate": "2026-03-12",
      "quantity": { "value": 1 },
      "unitPrice": { "value": 109.51, "currency": "USD" },
      "net": { "value": 109.51, "currency": "USD" },
      "adjudication": [
        { "category": { "coding": [ { "code": "submitted" } ] }, "amount": { "value": 109.51, "currency": "USD" } },
        { "category": { "coding": [ { "code": "eligible" } ] }, "amount": { "value": 87.61, "currency": "USD" } }
      ]
    }
  ],
  "total": [
    { "category": { "coding": [ { "code": "submitted" } ] }, "amount": { "value": 109.51, "currency": "USD" } },
    { "category": { "coding": [ { "code": "benefit" } ] }, "amount": { "value": 70.09, "currency": "USD" } }
  ],
  "payment": {
    "type": { "coding": [ { "code": "complete" } ] },
    "amount": { "value": 70.09, "currency": "USD" },
    "date": "2026-04-25"
  }
}

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