{
  "title": "Health insurance explanation-of-benefits records for AI",
  "source_page": "https://fiund.com/industries/health-insurance-eob-adjustment-data",
  "authorship": "Original fictional Fiund editorial exercise. No actual operating records or third-party source assets are included.",
  "example": {
    "title": "A corrected allowed amount is distinct from a payment or provider bill",
    "context": "An original mock explanation-of-benefits card has generic service labels and arbitrary units. There are no patients, real providers, health codes or claims behind it.",
    "records": [
      [
        "EB1",
        "EOB version 1",
        "Service A: billed 100, allowed 70, plan paid 50. Service B: billed 60, allowed 40, plan paid 30. All values practice units."
      ],
      [
        "EB2",
        "EOB correction v2",
        "Explicitly replaces A's allowed amount with 75. A's billed 100 and plan-paid 50 unchanged; B unchanged. No patient-responsibility field supplied."
      ],
      [
        "EB3",
        "Separate provider card",
        "A statement labeled provider bill lists 45 units but gives no service-line mapping or reconciliation with the EOB."
      ]
    ],
    "question": "What changed in the corrected EOB, and can the packet establish an additional payment or a patient amount due?",
    "answer": "EB2 changes only service A's allowed amount from 70 to 75 practice units. Its billed and plan-paid fields remain 100 and 50, and service B is unchanged. That five-unit allowed-amount change is not a documented extra payment. EB3 is a different record type with no line mapping, while patient responsibility is absent from the EOB cards. Flag the reconciliation gap rather than calculating a bill or coverage outcome from incomplete fields.",
    "failureModes": [
      "Calling an allowed-amount adjustment an additional plan payment.",
      "Treating the EOB as a bill or deriving responsibility from an unexplained provider statement."
    ],
    "fields": [
      [
        "Service-line reference and version",
        "Limits the correction to its target."
      ],
      [
        "Amount type and value",
        "Separates billed, allowed and paid figures."
      ],
      [
        "Record class and missing mapping",
        "Makes unresolved reconciliation explicit."
      ]
    ],
    "holdout": "Add a separate payment confirmation for A, dated later. Require it to be identified as new payment evidence rather than retroactively attributed to EB2.",
    "boundary": "Use synthetic documents reviewed for terminology. Exclude actual claims, member IDs, confidential reimbursement data and coverage or appeal decisions."
  }
}