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: EOB Inpatient Institutional - Example 1

Generated Narrative

Resource "InpatientEOBExample1" Updated "2020-04-28 03:39:36-0400"

Information Source: Organization/PayerOrganizationExample1!

Profile: C4BB ExplanationOfBenefit Inpatient Institutional (version 1.2.0)

identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1

status: active

type: Institutional (Claim Type Codes#institutional)

subType: Inpatient (C4BB Institutional Claim SubType#inpatient)

use: claim

patient: Patient/ExamplePatient1 " TEST"

billablePeriod: 2017-05-23 --> 2017-05-23

created: 2017-06-01 12:00:00-0400

insurer: Organization/PayerOrganizationExample1: UPMC Health Plan "UPMC Health Plan"

provider: Organization/ProviderOrganization3 "Green Medical Group"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (ClaimPayeeTypeCodes#provider "Provider")Organization/ProviderOrganization4 "Blue Medical Group"

outcome: complete

careTeam

sequence: 1

provider: Practitioner/Practitioner2 " BROWN"

role: The attending physician (C4BB Claim Care Team Role#attending "Attending")

careTeam

sequence: 2

provider: Practitioner/Practitioner2 " BROWN"

role: The referring physician (C4BB Claim Care Team Role#referring "Referring")

supportingInfo

sequence: 1

category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. (C4BB Supporting Info Type#billingnetworkcontractingstatus "Billing Network Contracting Status")

code: Indicates the provider was contracted for the service (C4BB Payer Adjudication Status#contracted "Contracted")

supportingInfo

sequence: 2

category: Date the claim was received by the payer. (C4BB Supporting Info Type#clmrecvddate "Claim Received Date")

timing: 2017-06-01

supportingInfo

sequence: 3

category: Dates corresponding with the admission and discharge of the beneficiary to a facility (C4BB Supporting Info Type#admissionperiod "Admission Period")

timing: 2017-05-23 --> (ongoing)

supportingInfo

sequence: 4

category: In Network (C4BB Payer Adjudication Status#innetwork)

diagnosis

sequence: 1

diagnosis: Non-ST elevation (NSTEMI) myocardial infarction (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I21.4)

type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. (Example Diagnosis Type Codes#principal "Principal Diagnosis")

diagnosis

sequence: 2

diagnosis: Athscl heart disease of native cor art w oth ang pctrs (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I25.118)

type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type#other "Other")

diagnosis

sequence: 3

diagnosis: Hyperlipidemia, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#E78.5)

type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type#other "Other")

diagnosis

sequence: 4

diagnosis: Unspecified osteoarthritis, unspecified site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#M19.90)

type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type#other "Other")

procedure

sequence: 1

type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis (C4BB Claim Procedure Type#principal "Principal")

date: 2017-05-23

procedure: 4A023N7 (ICD-10 Procedure Codes#4A023N7)

procedure

sequence: 2

type: Other procedures performed during the inpatient institutional admission (C4BB Claim Procedure Type#other "Other")

date: 2017-05-23

procedure: B211YZZ (ICD-10 Procedure Codes#B211YZZ)

procedure

sequence: 3

type: Other procedures performed during the inpatient institutional admission (C4BB Claim Procedure Type#other "Other")

date: 2017-05-23

procedure: B215YZZ (ICD-10 Procedure Codes#B215YZZ)

Insurances

-FocalCoverage
*trueCoverage/CoverageEx2

item

sequence: 1

revenue: 0301 (NUBC Revenue Codes#0301)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 2

revenue: 0260 (NUBC Revenue Codes#0260)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 3

revenue: 0305 (NUBC Revenue Codes#0305)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 4

revenue: 0324 (NUBC Revenue Codes#0324)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 5

revenue: 0259 (NUBC Revenue Codes#0259)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 6

revenue: 0250 (NUBC Revenue Codes#0250)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 7

revenue: 0710 (NUBC Revenue Codes#0710)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 8

revenue: 0210 (NUBC Revenue Codes#0210)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 9

revenue: 0272 (NUBC Revenue Codes#0272)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 10

revenue: 0370 (NUBC Revenue Codes#0370)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 11

revenue: 0730 (NUBC Revenue Codes#0730)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 12

revenue: 0450 (NUBC Revenue Codes#0450)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 13

revenue: 0481 (NUBC Revenue Codes#0481)

productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. (C4BB Adjudication#noncovered "Noncovered")

total

category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")

total

category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")

total

category: Amount deducted from the eligible amount prior to adjudication. (Adjudication Value Codes#deductible "Deductible")

total

category: Patient Co-Payment (Adjudication Value Codes#copay "CoPay")

total

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. (C4BB Adjudication#noncovered "Noncovered")

total

category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")

total

category: The amount of the member's liability. (C4BB Adjudication#memberliability "Member liability")

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "InpatientEOBExample1"
meta.lastUpdated "2020-04-28T15:39:36-04:00"
meta.source "Organization/PayerOrganizationExample1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].display "Unique Claim ID"
identifier[0].type.text "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
identifier[0].system "https://www.upmchealthplan.com/fhir/EOBIdentifier"
identifier[0].value InpatientEOBExample1
status "active"
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.coding[0].code #institutional
type.text "Institutional"
subType.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"
subType.coding[0].code #inpatient
subType.text "Inpatient"
use "claim"
patient.reference "Patient/ExamplePatient1"
billablePeriod.start "2017-05-23"
billablePeriod.end "2017-05-23"
created "2017-06-01T00:00:00-04:00"
insurer.reference "Organization/PayerOrganizationExample1"
insurer.display "UPMC Health Plan"
provider.reference "Organization/ProviderOrganization3"
payee.type.coding[0].system "http://terminology.hl7.org/CodeSystem/payeetype"
payee.type.coding[0].code #provider
payee.type.coding[0].display "Provider"
payee.type.text "Any benefit payable will be paid to the provider (Assignment of Benefit)."
payee.party.reference "Organization/ProviderOrganization4"
outcome "complete"
careTeam[0].sequence 1
careTeam[0].provider.reference "Practitioner/Practitioner2"
careTeam[0].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[0].role.coding[0].code #attending
careTeam[0].role.coding[0].display "Attending"
careTeam[0].role.text "The attending physician"
careTeam[1].sequence 2
careTeam[1].provider.reference "Practitioner/Practitioner2"
careTeam[1].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[1].role.coding[0].code #referring
careTeam[1].role.coding[0].display "Referring"
careTeam[1].role.text "The referring physician"
supportingInfo[0].sequence 1
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].category.coding[0].display "Billing Network Contracting Status"
supportingInfo[0].category.text "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[0].code.coding[0].display "Contracted"
supportingInfo[0].code.text "Indicates the provider was contracted for the service"
supportingInfo[1].sequence 2
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].category.coding[0].code #clmrecvddate
supportingInfo[1].category.coding[0].display "Claim Received Date"
supportingInfo[1].category.text "Date the claim was received by the payer."
supportingInfo[1].timingDate "2017-06-01"
supportingInfo[2].sequence 3
supportingInfo[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[2].category.coding[0].code #admissionperiod
supportingInfo[2].category.coding[0].display "Admission Period"
supportingInfo[2].category.text "Dates corresponding with the admission and discharge of the beneficiary to a facility"
supportingInfo[2].timingPeriod.start "2017-05-23"
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #I21.4
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].type[0].coding[0].code #principal
diagnosis[0].type[0].coding[0].display "Principal Diagnosis"
diagnosis[0].type[0].text "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
diagnosis[1].sequence 2
diagnosis[1].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[1].diagnosisCodeableConcept.coding[0].code #I25.118
diagnosis[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[1].type[0].coding[0].code #other
diagnosis[1].type[0].coding[0].display "Other"
diagnosis[1].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[2].sequence 3
diagnosis[2].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[2].diagnosisCodeableConcept.coding[0].code #E78.5
diagnosis[2].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[2].type[0].coding[0].code #other
diagnosis[2].type[0].coding[0].display "Other"
diagnosis[2].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[3].sequence 4
diagnosis[3].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[3].diagnosisCodeableConcept.coding[0].code #M19.90
diagnosis[3].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[3].type[0].coding[0].code #other
diagnosis[3].type[0].coding[0].display "Other"
diagnosis[3].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
procedure[0].sequence 1
procedure[0].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[0].type[0].coding[0].code #principal
procedure[0].type[0].coding[0].display "Principal"
procedure[0].type[0].text "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
procedure[0].date "2017-05-23"
procedure[0].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[0].procedureCodeableConcept.coding[0].code #4A023N7
procedure[1].sequence 2
procedure[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[1].type[0].coding[0].code #other
procedure[1].type[0].coding[0].display "Other"
procedure[1].type[0].text "Other procedures performed during the inpatient institutional admission"
procedure[1].date "2017-05-23"
procedure[1].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[1].procedureCodeableConcept.coding[0].code #B211YZZ
procedure[2].sequence 3
procedure[2].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[2].type[0].coding[0].code #other
procedure[2].type[0].coding[0].display "Other"
procedure[2].type[0].text "Other procedures performed during the inpatient institutional admission"
procedure[2].date "2017-05-23"
procedure[2].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[2].procedureCodeableConcept.coding[0].code #B215YZZ
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageEx2"
item[0].sequence 1
item[0].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[0].revenue.coding[0].code #0301
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].code #99231
item[0].servicedPeriod.start "2017-05-23"
item[0].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[0].locationCodeableConcept.coding[0].code #21
item[0].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[1].sequence 2
item[1].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[1].revenue.coding[0].code #0260
item[1].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[1].productOrService.coding[0].code #99231
item[1].servicedPeriod.start "2017-05-23"
item[1].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[1].locationCodeableConcept.coding[0].code #21
item[1].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[2].sequence 3
item[2].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[2].revenue.coding[0].code #0305
item[2].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[2].productOrService.coding[0].code #99231
item[2].servicedPeriod.start "2017-05-23"
item[2].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[2].locationCodeableConcept.coding[0].code #21
item[2].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[3].sequence 4
item[3].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[3].revenue.coding[0].code #0324
item[3].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[3].productOrService.coding[0].code #99231
item[3].servicedPeriod.start "2017-05-23"
item[3].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[3].locationCodeableConcept.coding[0].code #21
item[3].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[4].sequence 5
item[4].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[4].revenue.coding[0].code #0259
item[4].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[4].productOrService.coding[0].code #99231
item[4].servicedPeriod.start "2017-05-23"
item[4].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[4].locationCodeableConcept.coding[0].code #21
item[4].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[5].sequence 6
item[5].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[5].revenue.coding[0].code #0250
item[5].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[5].productOrService.coding[0].code #99231
item[5].servicedPeriod.start "2017-05-23"
item[5].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[5].locationCodeableConcept.coding[0].code #21
item[5].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[6].sequence 7
item[6].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[6].revenue.coding[0].code #0710
item[6].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[6].productOrService.coding[0].code #99231
item[6].servicedPeriod.start "2017-05-23"
item[6].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[6].locationCodeableConcept.coding[0].code #21
item[6].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[7].sequence 8
item[7].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[7].revenue.coding[0].code #0210
item[7].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[7].productOrService.coding[0].code #99231
item[7].servicedPeriod.start "2017-05-23"
item[7].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[7].locationCodeableConcept.coding[0].code #21
item[7].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[8].sequence 9
item[8].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[8].revenue.coding[0].code #0272
item[8].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[8].productOrService.coding[0].code #99231
item[8].servicedPeriod.start "2017-05-23"
item[8].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[8].locationCodeableConcept.coding[0].code #21
item[8].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[9].sequence 10
item[9].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[9].revenue.coding[0].code #0370
item[9].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[9].productOrService.coding[0].code #99231
item[9].servicedPeriod.start "2017-05-23"
item[9].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[9].locationCodeableConcept.coding[0].code #21
item[9].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[10].sequence 11
item[10].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[10].revenue.coding[0].code #0730
item[10].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[10].productOrService.coding[0].code #99231
item[10].servicedPeriod.start "2017-05-23"
item[10].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[10].locationCodeableConcept.coding[0].code #21
item[10].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[11].sequence 12
item[11].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[11].revenue.coding[0].code #0450
item[11].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[11].productOrService.coding[0].code #99231
item[11].servicedPeriod.start "2017-05-23"
item[11].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[11].locationCodeableConcept.coding[0].code #21
item[11].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[12].sequence 13
item[12].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[12].revenue.coding[0].code #0481
item[12].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[12].productOrService.coding[0].code #99231
item[12].servicedPeriod.start "2017-05-23"
item[12].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[12].locationCodeableConcept.coding[0].code #21
item[12].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
adjudication[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
adjudication[0].category.coding[0].code #noncovered
adjudication[0].category.coding[0].display "Noncovered"
adjudication[0].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
adjudication[0].amount.value 0.0
adjudication[0].amount.currency #USD
total[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[0].category.coding[0].code #submitted
total[0].category.coding[0].display "Submitted Amount"
total[0].category.text "The total submitted amount for the claim or group or line item."
total[0].amount.value 7147.2
total[0].amount.currency #USD
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.coding[0].code #eligible
total[1].category.coding[0].display "Eligible Amount"
total[1].category.text "Amount of the change which is considered for adjudication."
total[1].amount.value 1542.01
total[1].amount.currency #USD
total[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[2].category.coding[0].code #deductible
total[2].category.coding[0].display "Deductible"
total[2].category.text "Amount deducted from the eligible amount prior to adjudication."
total[2].amount.value 0.0
total[2].amount.currency #USD
total[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[3].category.coding[0].code #copay
total[3].category.coding[0].display "CoPay"
total[3].category.text "Patient Co-Payment"
total[3].amount.value 120.0
total[3].amount.currency #USD
total[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[4].category.coding[0].code #noncovered
total[4].category.coding[0].display "Noncovered"
total[4].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
total[4].amount.value 0.0
total[4].amount.currency #USD
total[5].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[5].category.coding[0].code #benefit
total[5].category.coding[0].display "Benefit Amount"
total[5].category.text "Amount payable under the coverage"
total[5].amount.value 1393.57
total[5].amount.currency #USD
total[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[6].category.coding[0].code #memberliability
total[6].category.coding[0].display "Member liability"
total[6].category.text "The amount of the member's liability."
total[6].amount.value 0.0
total[6].amount.currency #USD
total[7].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
total[7].category.coding[0].code #innetwork
total[7].amount.value 0.0
total[7].amount.currency #USD