CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Pre-Publish United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.2.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Example ExplanationOfBenefit: EOBProfessional1a

Generated Narrative

Resource "EOBProfessional1a" Updated "2019-12-12 09:14:11+0000" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Professional NonClinician (version 1.2.0)

identifier: Unique Claim ID: AW123412341234123412341234123413

status: active

type: Professional (Claim Type Codes#professional)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2019-01-01 --> 2019-10-31

created: 2019-07-02 12:00:00+0000

insurer: Organization/Payer1: XXX Health Plan "Payer 1"

provider: Organization/OrganizationProvider1: XXX Health Plan "Provider 1"

outcome: partial

supportingInfo

sequence: 1

category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)

code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo

sequence: 2

category: Performing Network Contracting Status (C4BB Supporting Info Type#performingnetworkcontractingstatus)

code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo

sequence: 3

category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)

timing: 2011-05-30

supportingInfo

sequence: 4

category: Service Facility (C4BB Supporting Info Type#servicefacility)

value: Organization/OrganizationProvider1 "Provider 1"

supportingInfo

sequence: 5

category: Medical Record Number (C4BB Supporting Info Type#medicalrecordnumber)

value: 1234-234-1243-12345678901m

supportingInfo

sequence: 6

category: Patient Account Number (C4BB Supporting Info Type#patientaccountnumber)

value: 1234-234-1243-12345678901a

Diagnoses

-SequenceDiagnosis[x]Type
*1Concussion w LOC of 30 minutes or less, init (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.0X1A)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

productOrService: Physical Therapy (Current Procedural Terminology (CPT®)#97110)

serviced: 2019-07-02

location: Office (CMS Place of Service Codes (POS)#11)

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)

adjudication

category: Other (C4BB Payer Adjudication Status#other)

total

category: Payment Amount (C4BB Adjudication#paidtoprovider)

total

category: Submitted Amount (Adjudication Value Codes#submitted)

total

category: Patient Pay Amount (C4BB Adjudication#paidbypatient)

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "EOBProfessional1a"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician"
meta.lastUpdated "2019-12-12T09:14:11+00:00"
type.coding[0].code #professional
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.text "Professional"
use "claim"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].sequence 1
supportingInfo[1].category.coding[0].code #performingnetworkcontractingstatus
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].code.coding[0].code #contracted
supportingInfo[1].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[1].sequence 2
supportingInfo[2].category.coding[0].code #clmrecvddate
supportingInfo[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[2].timingDate "2011-05-30"
supportingInfo[2].sequence 3
supportingInfo[3].category.coding[0].code #servicefacility
supportingInfo[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[3].sequence 4
supportingInfo[3].valueReference.reference "Organization/OrganizationProvider1"
supportingInfo[4].category.coding[0].code #medicalrecordnumber
supportingInfo[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[4].valueString "1234-234-1243-12345678901m"
supportingInfo[4].sequence 5
supportingInfo[5].category.coding[0].code #patientaccountnumber
supportingInfo[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[5].valueString "1234-234-1243-12345678901a"
supportingInfo[5].sequence 6
language "en-US"
status "active"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].value AW123412341234123412341234123413
identifier[0].system "https://www.xxxplan.com/fhir/EOBIdentifier"
created "2019-07-02T00:00:00+00:00"
insurer.reference "Organization/Payer1"
insurer.display "XXX Health Plan"
patient.reference "Patient/Patient1"
billablePeriod.start "2019-01-01"
billablePeriod.end "2019-10-31"
provider.reference "Organization/OrganizationProvider1"
provider.display "XXX Health Plan"
outcome "partial"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #S06.0X1A
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].type[0].coding[0].code #principal
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].sequence 1
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/Coverage1"
total[0].category.coding[0].code #paidtoprovider
total[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[0].category.text "Payment Amount"
total[0].amount.value 620
total[0].amount.currency #USD
total[1].category.coding[0].code #submitted
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.text "Submitted Amount"
total[1].amount.value 2650
total[1].amount.currency #USD
total[2].category.coding[0].code #paidbypatient
total[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[2].category.text "Patient Pay Amount"
total[2].amount.value 0
total[2].amount.currency #USD
item[0].productOrService.coding[0].code #97110
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].display "Physical Therapy"
item[0].sequence 1
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].amount.value 1000
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].code #other
item[0].adjudication[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"