CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

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 Professional - Example 2 - Nonfinancial - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="BB-EOBProfessional2-nonfinancial"/>
  <meta>
    <lastUpdated value="2020-10-20T14:46:05-04:00"/>
    <source value="Organization/PayerOrganizationExample1"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician-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-EOBProfessional2-nonfinancial</b></p><a name="BB-EOBProfessional2-nonfinancial"> </a><a name="hcBB-EOBProfessional2-nonfinancial"> </a><a name="BB-EOBProfessional2-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: 2020-10-20 14:46:05-0400; </p><p style="margin-bottom: 0px">Information Source: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&amp;canonical=http://hl7.org/fhir/us/core/Organization/PayerOrganizationExample1">Organization/PayerOrganizationExample1</a></p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Professional-NonClinician-Basis.html">C4BB ExplanationOfBenefit Professional NonClinician 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/ProfessionalEOBExample1</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</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>: 2020-08-04 --&gt; 2020-08-04</p><p><b>created</b>: 2020-08-24 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-ProviderOrganization1.html">Organization Orange 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-ProviderOrganization1.html">Organization Orange 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-Practitioner1.html">Practitioner John Smith </a></p><p><b>role</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claimcareteamrole primary}">The primary care provider.</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><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Date the claim was received by the payer.</span></td><td>2020-08-24</td></tr></table><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 I70.249}">Athscl native arteries of left leg w ulceration of unsp site</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 L97.929}">Non-prs chronic ulc unsp prt of l low leg w unsp severity</span></p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType secondary}">Required when necessary to report additional diagnoses on professional and non-clinician claims</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-Coverage1.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 = 2020-01-01 --&gt; (ongoing); network = GR5-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 75710}">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 75710}">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 75710}">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 37228}">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 37228}">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 37228}">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</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><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 innetwork}">In Network</span></td></tr></table></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 billingnetworkstatus}">Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.</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="ProfessionalEOBExample1"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
    </coding>
    <text value="Professional"/>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient1"/>
  </patient>
  <billablePeriod>
    <start value="2020-08-04"/>
    <end value="2020-08-04"/>
  </billablePeriod>
  <created value="2020-08-24T00:00:00-04:00"/>
  <insurer>🔗 
    <reference value="Organization/Payer2"/>
    <display value="UPMC Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ProviderOrganization1"/>
  </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/ProviderOrganization1"/>
    </party>
  </payee>
  <outcome value="complete"/>
  <careTeam>
    <sequence value="1"/>
    <provider>🔗 
      <reference value="Practitioner/Practitioner1"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/claimcareteamrole"/>
        <version value="1.0.0"/>
        <code value="primary"/>
        <display value="Primary provider"/>
      </coding>
      <text value="The primary care provider."/>
    </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="1"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
        <display value="Claim Received Date"/>
      </coding>
      <text value="Date the claim was received by the payer."/>
    </category>
    <timingDate value="2020-08-24"/>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="I70.249"/>
      </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="L97.929"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="secondary"/>
        <display value="secondary"/>
      </coding>
      <text
            value="Required when necessary to report additional diagnoses on professional and non-clinician claims"/>
    </type>
  </diagnosis>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/Coverage1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="75710"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <item>
    <sequence value="2"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="75710"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <item>
    <sequence value="3"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="75710"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <item>
    <sequence value="4"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="37228"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <item>
    <sequence value="5"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="37228"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <item>
    <sequence value="6"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="37228"/>
      </coding>
    </productOrService>
    <servicedDate value="2020-08-04"/>
    <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>
    <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="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
        <display value="Billing Network Status"/>
      </coding>
      <text
            value="Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."/>
    </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>