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 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 Outpatient Institutional - Example 1

Generated Narrative

Resource "OutpatientEOBExample1" Updated "2020-10-13 11:10:24-0400"

Information Source: Organization/PayerOrganizationExample1!

Profile: C4BB ExplanationOfBenefit Outpatient 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: OutpatientEOBExample1

status: active

type: Institutional (Claim Type Codes#institutional)

subType: Outpatient (C4BB Institutional Claim SubType#outpatient)

use: claim

patient: Patient/ExamplePatient1 " TEST"

billablePeriod: 2020-09-29 --> 2020-09-29

created: 2020-10-10 12:00:00-0400

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

provider: Organization/ProviderOrganization5 "Black Medical Group"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (ClaimPayeeTypeCodes#provider "Provider")Organization/ProviderOrganization6 "White Medical Group"

outcome: complete

careTeam

sequence: 1

provider: Practitioner/Practitioner1 " SMITH"

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

careTeam

sequence: 2

provider: Practitioner/Practitioner3 " WILLIAMS"

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: 2020-10-10

supportingInfo

sequence: 3

category: Out Of Network (C4BB Payer Adjudication Status#outofnetwork)

diagnosis

sequence: 1

diagnosis: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)

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: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)

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

diagnosis

sequence: 3

diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#L97.529)

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

diagnosis

sequence: 4

diagnosis: Peripheral vascular disease, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I73.9)

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

Insurances

-FocalCoverage
*trueCoverage/CoverageEx1

item

sequence: 1

revenue: 0551 (NUBC Revenue Codes#0551)

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

serviced: 2020-09-29

location: HOME (CMS Place of Service Codes (POS)#12)

adjudication

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

adjudication

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

adjudication

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

adjudication

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

adjudication

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

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")

item

sequence: 2

revenue: 0023 (NUBC Revenue Codes#0023)

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

serviced: 2020-09-29

location: HOME (CMS Place of Service Codes (POS)#12)

adjudication

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

adjudication

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

adjudication

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

adjudication

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

adjudication

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

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 "OutpatientEOBExample1"
meta.lastUpdated "2020-10-13T11:10:24-04:00"
meta.source "Organization/PayerOrganizationExample1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-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 OutpatientEOBExample1
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 #outpatient
subType.text "Outpatient"
use "claim"
patient.reference "Patient/ExamplePatient1"
billablePeriod.start "2020-09-29"
billablePeriod.end "2020-09-29"
created "2020-10-10T00:00:00-04:00"
insurer.reference "Organization/PayerOrganizationExample1"
insurer.display "UPMC Health Plan"
provider.reference "Organization/ProviderOrganization5"
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/ProviderOrganization6"
outcome "complete"
careTeam[0].sequence 1
careTeam[0].provider.reference "Practitioner/Practitioner1"
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/Practitioner3"
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 "2020-10-10"
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #I95.1
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 #I95.1
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 #L97.529
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 #I73.9
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"
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageEx1"
item[0].sequence 1
item[0].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[0].revenue.coding[0].code #0551
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].code #99231
item[0].servicedDate "2020-09-29"
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 #12
item[0].locationCodeableConcept.text "HOME"
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].display "Submitted Amount"
item[0].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[0].adjudication[0].amount.value 84.4
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[1].category.coding[0].code #copay
item[0].adjudication[1].category.coding[0].display "CoPay"
item[0].adjudication[1].category.text "Patient Co-Payment"
item[0].adjudication[1].amount.value 0.0
item[0].adjudication[1].amount.currency #USD
item[0].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[2].category.coding[0].code #eligible
item[0].adjudication[2].category.coding[0].display "Eligible Amount"
item[0].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[0].adjudication[2].amount.value 56.52
item[0].adjudication[2].amount.currency #USD
item[0].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[3].category.coding[0].code #deductible
item[0].adjudication[3].category.coding[0].display "Deductible"
item[0].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[0].adjudication[3].amount.value 0.0
item[0].adjudication[3].amount.currency #USD
item[0].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[4].category.coding[0].code #benefit
item[0].adjudication[4].category.coding[0].display "Benefit Amount"
item[0].adjudication[4].category.text "Amount payable under the coverage"
item[0].adjudication[4].amount.value 56.52
item[0].adjudication[4].amount.currency #USD
item[0].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[5].category.coding[0].code #noncovered
item[0].adjudication[5].category.coding[0].display "Noncovered"
item[0].adjudication[5].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."
item[0].adjudication[5].amount.value 0.0
item[0].adjudication[5].amount.currency #USD
item[1].sequence 2
item[1].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[1].revenue.coding[0].code #0023
item[1].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[1].productOrService.coding[0].code #99231
item[1].servicedDate "2020-09-29"
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 #12
item[1].locationCodeableConcept.text "HOME"
item[1].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[0].category.coding[0].code #submitted
item[1].adjudication[0].category.coding[0].display "Submitted Amount"
item[1].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[1].adjudication[0].amount.value 0.0
item[1].adjudication[0].amount.currency #USD
item[1].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[1].category.coding[0].code #copay
item[1].adjudication[1].category.coding[0].display "CoPay"
item[1].adjudication[1].category.text "Patient Co-Payment"
item[1].adjudication[1].amount.value 0.0
item[1].adjudication[1].amount.currency #USD
item[1].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[2].category.coding[0].code #eligible
item[1].adjudication[2].category.coding[0].display "Eligible Amount"
item[1].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[1].adjudication[2].amount.value 0.0
item[1].adjudication[2].amount.currency #USD
item[1].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[3].category.coding[0].code #deductible
item[1].adjudication[3].category.coding[0].display "Deductible"
item[1].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[1].adjudication[3].amount.value 0.0
item[1].adjudication[3].amount.currency #USD
item[1].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[4].category.coding[0].code #benefit
item[1].adjudication[4].category.coding[0].display "Benefit Amount"
item[1].adjudication[4].category.text "Amount payable under the coverage"
item[1].adjudication[4].amount.value 0.0
item[1].adjudication[4].amount.currency #USD
item[1].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[1].adjudication[5].category.coding[0].code #noncovered
item[1].adjudication[5].category.coding[0].display "Noncovered"
item[1].adjudication[5].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."
item[1].adjudication[5].amount.value 0.0
item[1].adjudication[5].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 84.4
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 56.52
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 0.0
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 56.52
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 #outofnetwork
total[7].amount.value 0.0
total[7].amount.currency #USD