CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
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CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0-snapshot1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOB Inpatient Institutional - Example 2 - Nonfinancial - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="BB-EOBInpatient2-nonfinancial"/>
  <meta>
    <lastUpdated value="2020-04-28T15:39:36-04:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis|2.1.0-snapshot1"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit BB-EOBInpatient2-nonfinancial</b></p><a name="BB-EOBInpatient2-nonfinancial"> </a><a name="hcBB-EOBInpatient2-nonfinancial"> </a><a name="BB-EOBInpatient2-nonfinancial-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2020-04-28 15:39:36-0400</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis.html">C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/InpatientEOBExample1</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>subType</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType inpatient}">Inpatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-Patient1.html">Johnny Example1  Male, DoB: 1986-01-01 ( Member Number)</a></p><p><b>billablePeriod</b>: 2017-05-23 --&gt; 2017-05-23</p><p><b>created</b>: 2017-06-01 00:00:00-0400</p><p><b>insurer</b>: <a href="Organization-Payer2.html">UPMC Health Plan</a></p><p><b>provider</b>: <a href="Organization-ProviderOrganization3.html">Organization Green Medical Group</a></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href="Organization-ProviderOrganization4.html">Organization Blue Medical Group</a></td></tr></table><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Practitioner Jack Brown </a></p><p><b>role</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole attending}">The attending physician</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Practitioner Jack Brown </a></p><p><b>role</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole referring}">The referring physician</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}">Admission Period</span></p><p><b>timing</b>: 2017-05-23 --&gt; (ongoing)</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Claim Received Date</span></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm I21.4}">Non-ST elevation (NSTEMI) myocardial infarction</span></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm I25.118}">Athscl heart disease of native cor art w oth ang pctrs</span></p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm E78.5}">Hyperlipidemia, unspecified</span></p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm M19.90}">Unspecified osteoarthritis, unspecified site</span></p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType principal}">The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/ICD10 4A023N7}">Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/ICD10 B211YZZ}">Fluoroscopy of Multiple Coronary Arteries using Other Contrast</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/ICD10 B215YZZ}">Fluoroscopy of Left Heart using Other Contrast</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Coverage-Coverage2.html">Coverage: identifier = An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status = active; subscriberId = 888009335; dependent = 01; relationship = Self; period = 2017-01-01 --&gt; 2017-06-30; network = GI8-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0301}">0301</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0260}">0260</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0305}">0305</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0324}">0324</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0259}">0259</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0250}">0250</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0710}">0710</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0210}">0210</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0272}">0272</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0370}">0370</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0730}">0730</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0450}">0450</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0481}">0481</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 99231}">Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus outofnetwork}">Out Of Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}">Billing Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the provider was in network for the service</span></td></tr></table></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
        <display value="Unique Claim ID"/>
      </coding>
      <text
            value="Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"/>
    </type>
    <system value="https://www.upmchealthplan.com/fhir/EOBIdentifier"/>
    <value value="InpatientEOBExample1"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
    <text value="Institutional"/>
  </type>
  <subType>
    <coding>
      <system
              value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
      <code value="inpatient"/>
    </coding>
    <text value="Inpatient"/>
  </subType>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient1"/>
  </patient>
  <billablePeriod>
    <start value="2017-05-23"/>
    <end value="2017-05-23"/>
  </billablePeriod>
  <created value="2017-06-01T00:00:00-04:00"/>
  <insurer>🔗 
    <reference value="Organization/Payer2"/>
    <display value="UPMC Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ProviderOrganization3"/>
  </provider>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
      </coding>
      <text
            value="Any benefit payable will be paid to the provider (Assignment of Benefit)."/>
    </type>
    <party>🔗 
      <reference value="Organization/ProviderOrganization4"/>
    </party>
  </payee>
  <outcome value="complete"/>
  <careTeam>
    <sequence value="1"/>
    <provider>🔗 
      <reference value="Practitioner/Practitioner2"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="attending"/>
        <display value="Attending"/>
      </coding>
      <text value="The attending physician"/>
    </role>
  </careTeam>
  <careTeam>
    <sequence value="2"/>
    <provider>🔗 
      <reference value="Practitioner/Practitioner2"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="referring"/>
        <display value="Referring"/>
      </coding>
      <text value="The referring physician"/>
    </role>
  </careTeam>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="admissionperiod"/>
      </coding>
    </category>
    <timingPeriod>
      <start value="2017-05-23"/>
    </timingPeriod>
  </supportingInfo>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2017-06-01"/>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="I21.4"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
        <code value="principal"/>
        <display value="Principal Diagnosis"/>
      </coding>
      <text
            value="The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="2"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="I25.118"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="3"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="E78.5"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="4"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="M19.90"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <procedure>
    <sequence value="1"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="principal"/>
        <display value="Principal"/>
      </coding>
      <text
            value="The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="4A023N7"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <procedure>
    <sequence value="2"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Other procedures performed during the inpatient institutional admission"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="B211YZZ"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <procedure>
    <sequence value="3"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Other procedures performed during the inpatient institutional admission"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="B215YZZ"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/Coverage2"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0301"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="2"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0260"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="3"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0305"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="4"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0324"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="5"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0259"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="6"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0250"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="7"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0710"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="8"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0210"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="9"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0272"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="10"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0370"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="11"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0730"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="12"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0450"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="13"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0481"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="outofnetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
        <display value="In Network"/>
      </coding>
      <text value="Indicates the provider was in network for the service"/>
    </reason>
  </adjudication>
</ExplanationOfBenefit>