Instance: Patient1 InstanceOf: C4BBPatient Description: "Patient Example1" Usage: #example //* id = "1234-234-1243-12345678901" //* meta.profile = Canonical(C4BBPatient) * meta.lastUpdated = "2020-07-07T13:26:22.0314215+00:00" * language = #en-US * id = "Patient1" * active = true * name[0].family = "Example1" * name[0].given[0] = "Johnny" * telecom[0].system = http://hl7.org/fhir/contact-point-system#phone * telecom[0].value = "(301)555-1212" * telecom[0].rank = 1 * telecom[0].system = http://hl7.org/fhir/contact-point-system#phone * telecom[0].value = "(301)666-1212" * telecom[0].rank = 2 * gender = http://hl7.org/fhir/administrative-gender#male * birthDate = "1986-01-01" * address[0].type = http://hl7.org/fhir/address-type#physical * address[0].line[0] = "123 Main Street" * address[0].city = "Pittsburgh" * address[0].state = "PA" * address[0].postalCode = "12519" * maritalStatus = http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK * identifier[memberid].type = $IdentifierType#MB * identifier[memberid].value = "1234-234-1243-12345678901" * identifier[memberid].system = "https://www.xxxhealthplan.com/fhir/memberidentifier" //* identifier[medrecnum].type = $IdentifierType#MR //* identifier[medrecnum].value = "1234-234-1243-12345678901m" //* identifier[medrecnum].system = "https://www.xxxhealthplan.com/fhir/medicalrecordnumber" * identifier[uniquememberid].type = C4BBIdentifierType#um * identifier[uniquememberid].value = "1234-234-1243-12345678901u" * identifier[uniquememberid].system = "https://www.xxxhealthplan.com/fhir/iniquememberidentifier" //* identifier[patacctnum].type = C4BBIdentifierType#pat //* identifier[patacctnum].value = "1234-234-1243-12345678901a" //* identifier[patacctnum].system = "https://www.xxxhealthplan.com/fhir/patacctnum" Instance: Coverage1 InstanceOf: C4BBCoverage Description: "Coverage Example1" Usage: #example //* id = "1234-234-1243-12345678901-20190101-20191031" * id = "Coverage1" //* meta.profile = Canonical(C4BBCoverage) * meta.lastUpdated = "2020-07-07T13:26:22.0314215+00:00" * language = #en-US * status = #active * identifier[0].type = $IdentifierType#MB * identifier[0].value = "1234-234-1243-12345678901" * identifier[0].system = "https://www.xxxhealthplan.com/fhir/memberidentifier" * type = http://terminology.hl7.org/CodeSystem/v3-ActCode#HIP * type.text = "health insurance plan policy" * policyHolder = Reference(Patient1) * subscriber = Reference(Patient1) * beneficiary = Reference(Patient1) * subscriberId = "12345678901" * dependent = "01" * period.start = "2019-01-01" * period.end = "2019-10-31" * class[group].type = $CoverageClassCS#group * class[group].type.text = "An employee group" * class[group].value = "021890" * class[group].name = "Acme Corporation" * class[plan].type = $CoverageClassCS#plan * class[plan].type.text = "Plan" * class[plan].value = "XYZ123" * class[plan].name = "XYZ123-UPMC CONSUMER ADVA" // * class[0].type = $CoverageClassCS#subgroup // * class[0].type.text = "A subgroup of an employee group" // * class[0].value = "300" // * class[0].name = "ACME HSA PPO 1500" * network = "XYZ123-UPMC CONSUMER ADVA" * relationship = http://terminology.hl7.org/CodeSystem/subscriber-relationship#self * payor = Reference(OrganizationPayer1) Instance: CoverageDental1 InstanceOf: C4BBCoverage Description: "Dental Coverage Example1" Usage: #example //* id = "1234-234-1243-12345678901-20190101-20191031" * id = "CoverageDental1" * meta.lastUpdated = "2021-01-01T14:22:01.0314215+00:00" * language = #en-US * status = #active * identifier[0].type = $IdentifierType#MB * identifier[0].value = "210300002" * identifier[0].system = "https://www.xxxhealthplan.com/fhir/memberidentifier" * type = http://terminology.hl7.org/CodeSystem/v3-ActCode#DENTAL * type.text = "dental care policy" * policyHolder = Reference(Patient1) * subscriber = Reference(Patient1) * beneficiary = Reference(Patient1) * subscriberId = "10300007" * dependent = "01" * period.start = "2021-01-01" * period.end = "2021-12-31" * class[group].type = $CoverageClassCS#group * class[group].type.text = "An employee group" * class[group].value = "10300007" * class[group].name = "Transcorp - dental" * class[plan].type = $CoverageClassCS#plan * class[plan].type.text = "Plan" * class[plan].value = "66783JJT" * class[plan].name = "INSURANCE COMPANY XYZ - PRIME" * network = "INSURANCE COMPANY XYZ - PRIME" * relationship = http://terminology.hl7.org/CodeSystem/subscriber-relationship#self * payor = Reference(OrganizationDentalPayer1) Instance: EOBInpatient1 InstanceOf: C4BBExplanationOfBenefitInpatientInstitutional Description: "EOB Inpatient Example1" Usage: #example * id = "EOBInpatient1" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitInpatientInstitutional) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * status = #active * identifier.type = C4BBIdentifierType#uc * identifier.value = "AW123412341234123412341234123412" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#institutional * type.text = "Institutional" * subType = C4BBInstitutionalClaimSubType#inpatient * subType.text = "Inpatient" * use = #claim * created = "2019-11-02T00:00:00+00:00" * insurer = Reference(OrganizationPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2019-01-01" * billablePeriod.end = "2019-10-31" * provider = Reference(OrganizationProvider1) * provider.display = "XXX Health Plan" * outcome = #partial * diagnosis[0].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A * diagnosis[0].type = $HL7DiagnosisType#principal * diagnosis[0].sequence = 1 * insurance[0].focal = true * insurance[0].coverage[0] = Reference(Coverage1) * item[0].sequence = 1 * item[0].productOrService = $HL7DataAbsentReason#not-applicable "Not Applicable" * item[0].revenue = AHANUBCRevenueCodes#Dummy * item[0].servicedDate = "2019-11-02" * adjudication[adjudicationamounttype][0].category = $C4BBAdjudicationCS#paidtoprovider * adjudication[adjudicationamounttype][0].category.text = "Payment Amount" * adjudication[adjudicationamounttype][0].amount.value = 620.00 * adjudication[adjudicationamounttype][0].amount.currency = #USD * adjudication[adjudicationamounttype][1].category = $HL7AdjudicationCS#submitted * adjudication[adjudicationamounttype][1].category.text = "Submitted Amount" * adjudication[adjudicationamounttype][1].amount.value = 2650.00 * adjudication[adjudicationamounttype][1].amount.currency = #USD * adjudication[adjudicationamounttype][2].category = $C4BBAdjudicationCS#paidbypatient * adjudication[adjudicationamounttype][2].category.text = "Patient Pay Amount" * adjudication[adjudicationamounttype][2].amount.value = 0.00 * adjudication[adjudicationamounttype][2].amount.currency = #USD * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[benefitpaymentstatus].category = C4BBAdjudicationDiscriminator#benefitpaymentstatus * adjudication[benefitpaymentstatus].reason = C4BBPayerAdjudicationStatus#innetwork * total[adjudicationamounttype][0].category = $C4BBAdjudicationCS#paidtoprovider * total[adjudicationamounttype][0].category.text = "Payment Amount" * total[adjudicationamounttype][0].amount.value = 620.00 * total[adjudicationamounttype][0].amount.currency = #USD * total[adjudicationamounttype][1].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][1].category.text = "Submitted Amount" * total[adjudicationamounttype][1].amount.value = 2650.00 * total[adjudicationamounttype][1].amount.currency = #USD * total[adjudicationamounttype][2].category = $C4BBAdjudicationCS#paidbypatient * total[adjudicationamounttype][2].category.text = "Patient Pay Amount" * total[adjudicationamounttype][2].amount.value = 0.00 * total[adjudicationamounttype][2].amount.currency = #USD //* adjudication[benefitpaymentstatus].category = C4BBAdjudication#innetwork * supportingInfo[admissionperiod].category = C4BBSupportingInfoType#admissionperiod * supportingInfo[admissionperiod].timingPeriod.start = 2011-05-23 * supportingInfo[admissionperiod].timingPeriod.end = 2011-05-25 * supportingInfo[admissionperiod].sequence = 2 * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2011-05-30 * supportingInfo[clmrecvddate].sequence = 3 * supportingInfo[typeofbill].category = C4BBSupportingInfoType#typeofbill * supportingInfo[typeofbill].code = AHANUBCTypeOfBill#Dummy * supportingInfo[typeofbill].sequence = 4 * supportingInfo[pointoforigin].category = C4BBSupportingInfoType#pointoforigin * supportingInfo[pointoforigin].code = AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn#Dummy * supportingInfo[pointoforigin].sequence = 5 * supportingInfo[admtype].category = C4BBSupportingInfoType#admtype * supportingInfo[admtype].code = AHANUBCPriorityTypeOfAdmissionOrVisit#Dummy * supportingInfo[admtype].sequence = 6 * supportingInfo[discharge-status].category = C4BBSupportingInfoType#discharge-status * supportingInfo[discharge-status].code = AHANUBCPatientDischargeStatus#11 * supportingInfo[discharge-status].sequence = 7 * supportingInfo[medicalrecordnumber].category = C4BBSupportingInfoType#medicalrecordnumber * supportingInfo[medicalrecordnumber].valueString = "1234-234-1243-12345678901m" * supportingInfo[medicalrecordnumber].sequence = 8 * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "1234-234-1243-12345678901a" * supportingInfo[patientaccountnumber].sequence = 9 Instance: EOBOutpatientInstitutional1 InstanceOf: C4BBExplanationOfBenefitOutpatientInstitutional Description: "EOB Outpatient Example1" Usage: #example * id = "EOBOutpatientInstitutional1" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitOutpatientInstitutional) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * status = #active * identifier.type = C4BBIdentifierType#uc * identifier.value = "AW123412341234123412341234123412" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#institutional * type.text = "Institutional" * subType = C4BBInstitutionalClaimSubType#outpatient * subType.text = "Outpatient" * use = #claim * created = "2019-11-02T00:00:00+00:00" * insurer = Reference(OrganizationPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2019-01-01" * billablePeriod.end = "2019-10-31" * provider = Reference(OrganizationProvider1) * provider.display = "XXX Health Plan" * careTeam[+].sequence = 1 * careTeam[=].provider = Reference(PractitionerProvider1) * careTeam[=].role = C4BBClaimCareTeamRole#rendering "Rendering provider" * careTeam[=].qualification = $NUCCProviderTaxonomy#364SX0200X "Oncology Clinical Nurse Specialist" * outcome = #partial * diagnosis[0].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A * diagnosis[0].type = $C4BBClaimDiagnosisTypeCS#patientreasonforvisit * diagnosis[0].sequence = 1 * insurance[0].focal = true * insurance[0].coverage[0] = Reference(Coverage1) * item[0].sequence = 1 * item[0].productOrService = $HL7DataAbsentReason#not-applicable "Not Applicable" * item[0].revenue = AHANUBCRevenueCodes#Dummy * item[0].servicedDate = "2019-11-02" * adjudication[adjudicationamounttype][0].category = C4BBAdjudication#paidtoprovider * adjudication[adjudicationamounttype][0].category.text = "Payment Amount" * adjudication[adjudicationamounttype][0].amount.value = 620.00 * adjudication[adjudicationamounttype][0].amount.currency = #USD * adjudication[adjudicationamounttype][1].category = C4BBAdjudication#paidbypatient * adjudication[adjudicationamounttype][1].category.text = "Patient Pay Amount" * adjudication[adjudicationamounttype][1].amount.value = 0.00 * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[benefitpaymentstatus].category = C4BBAdjudicationDiscriminator#benefitpaymentstatus * adjudication[benefitpaymentstatus].reason = C4BBPayerAdjudicationStatus#innetwork * total[adjudicationamounttype][2].amount.currency = #USD * total[adjudicationamounttype][0].category = $C4BBAdjudicationCS#paidtoprovider * total[adjudicationamounttype][0].category.text = "Payment Amount" * total[adjudicationamounttype][0].amount.value = 620.00 * total[adjudicationamounttype][0].amount.currency = #USD * total[adjudicationamounttype][1].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][1].category.text = "Submitted Amount" * total[adjudicationamounttype][1].amount.value = 2650.00 * total[adjudicationamounttype][1].amount.currency = #USD * total[adjudicationamounttype][2].category = $C4BBAdjudicationCS#paidbypatient * total[adjudicationamounttype][2].category.text = "Patient Pay Amount" * total[adjudicationamounttype][2].amount.value = 0.00 * total[adjudicationamounttype][2].amount.currency = #USD * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2019-11-30 * supportingInfo[clmrecvddate].sequence = 2 * supportingInfo[typeofbill].category = C4BBSupportingInfoType#typeofbill * supportingInfo[typeofbill].code = AHANUBCTypeOfBill#Dummy * supportingInfo[typeofbill].sequence = 3 * supportingInfo[pointoforigin].category = C4BBSupportingInfoType#pointoforigin * supportingInfo[pointoforigin].code = AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn#Dummy * supportingInfo[pointoforigin].sequence = 4 * supportingInfo[admtype].category = C4BBSupportingInfoType#admtype * supportingInfo[admtype].code = AHANUBCPriorityTypeOfAdmissionOrVisit#Dummy * supportingInfo[admtype].sequence = 5 * supportingInfo[discharge-status].category = C4BBSupportingInfoType#discharge-status * supportingInfo[discharge-status].code = AHANUBCPatientDischargeStatus#Dummy * supportingInfo[discharge-status].sequence = 6 * supportingInfo[medicalrecordnumber].category = C4BBSupportingInfoType#medicalrecordnumber * supportingInfo[medicalrecordnumber].valueString = "1234-234-1243-12345678901m" * supportingInfo[medicalrecordnumber].sequence = 7 * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "1234-234-1243-12345678901a" * supportingInfo[patientaccountnumber].sequence = 8 Instance: EOBProfessional1a InstanceOf: C4BBExplanationOfBenefitProfessionalNonClinician Description: "EOB Professional Example1" Usage: #example * id = "EOBProfessional1a" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitProfessionalNonClinician) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * status = #active * identifier.type = $C4BBIdentifierTypeCS#uc * identifier.value = "AW123412341234123412341234123413" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#professional * type.text = "Professional" * use = #claim * created = "2019-07-02T00:00:00+00:00" * insurer = Reference(OrganizationPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2019-01-01" * billablePeriod.end = "2019-10-31" * provider = Reference(OrganizationProvider1) * provider.display = "XXX Health Plan" * outcome = #partial * diagnosis[0].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A * diagnosis[0].type = $HL7DiagnosisType#principal * diagnosis[0].sequence = 1 * insurance[0].focal = true * insurance[0].coverage[0] = Reference(Coverage1) * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[renderingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#renderingnetworkcontractingstatus * adjudication[renderingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * total[adjudicationamounttype][0].category = $C4BBAdjudicationCS#paidtoprovider * total[adjudicationamounttype][0].category.text = "Payment Amount" * total[adjudicationamounttype][0].amount.value = 620.00 * total[adjudicationamounttype][0].amount.currency = #USD * total[adjudicationamounttype][1].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][1].category.text = "Submitted Amount" * total[adjudicationamounttype][1].amount.value = 2650.00 * total[adjudicationamounttype][1].amount.currency = #USD * total[adjudicationamounttype][2].category = $C4BBAdjudicationCS#paidbypatient * total[adjudicationamounttype][2].category.text = "Patient Pay Amount" * total[adjudicationamounttype][2].amount.value = 0.00 * total[adjudicationamounttype][2].amount.currency = #USD /*Testing for DAR*/ //* item[0].productOrService = $HL7DataAbsentReason#not-applicable "Not Applicable" * item[0].productOrService = $CPT#97110 "Physical Therapy" * item[0].sequence = 1 * item[0].servicedDate = "2019-07-02" * item[0].locationCodeableConcept = $CMSPlaceofServiceCodes#11 "Office" * item[0].adjudication[adjudicationamounttype][0].category = $HL7AdjudicationCS#submitted * item[0].adjudication[adjudicationamounttype][0].amount.value = 1000.00 * item[0].adjudication[adjudicationamounttype][0].amount.currency = #USD * item[0].adjudication[benefitpaymentstatus][0].category.coding[0] = C4BBPayerAdjudicationStatus#other * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2011-05-30 * supportingInfo[clmrecvddate].sequence = 3 * supportingInfo[servicefacility].category = C4BBSupportingInfoType#servicefacility * supportingInfo[servicefacility].sequence = 4 * supportingInfo[servicefacility].valueReference = Reference(OrganizationProvider1) * supportingInfo[medicalrecordnumber].category = C4BBSupportingInfoType#medicalrecordnumber * supportingInfo[medicalrecordnumber].valueString = "1234-234-1243-12345678901m" * supportingInfo[medicalrecordnumber].sequence = 5 * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "1234-234-1243-12345678901a" * supportingInfo[patientaccountnumber].sequence = 6 Instance: EOBOral1a InstanceOf: C4BBExplanationOfBenefitOral Description: "EOB Oral Example1" Usage: #example * id = "EOBOral1a" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitOral) * meta.lastUpdated = "2021-03-18T10:23:00-05:00" * language = #en-US * status = #active * identifier.type = $C4BBIdentifierTypeCS#uc * identifier.value = "210300002" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#oral * type.text = "Oral" * use = #claim * created = "2021-03-18T10:23:00-05:00" * insurer = Reference(OrganizationDentalPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2021-03-01" * billablePeriod.end = "2021-03-31" * provider = Reference(PractitionerDentalProvider1) * provider.display = "XXX Dental Plan" * outcome = #complete * diagnosis[0].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#Z01.21 "Encounter for dental examination and cleaning with abnormal findings" * diagnosis[0].type = $HL7DiagnosisType#principal * diagnosis[0].sequence = 1 * insurance[0].focal = true * insurance[0].coverage[0] = Reference(CoverageDental1) * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[renderingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#renderingnetworkcontractingstatus * adjudication[renderingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[benefitpaymentstatus].category = C4BBAdjudicationDiscriminator#benefitpaymentstatus * adjudication[benefitpaymentstatus].reason = C4BBPayerAdjudicationStatus#innetwork * total[adjudicationamounttype][0].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][0].category.text = "Submitted Amount" * total[adjudicationamounttype][0].amount.value = 410.00 * total[adjudicationamounttype][0].amount.currency = #USD * total[adjudicationamounttype][1].category = $HL7AdjudicationCS#benefit * total[adjudicationamounttype][1].category.text = "Benefit Amount" * total[adjudicationamounttype][1].amount.value = 350.00 * total[adjudicationamounttype][1].amount.currency = #USD * total[adjudicationamounttype][2].category = C4BBAdjudication#discount * total[adjudicationamounttype][2].category.text = "Discount Amount" * total[adjudicationamounttype][2].amount.value = 60.00 * total[adjudicationamounttype][2].amount.currency = #USD * total[adjudicationamounttype][3].category = C4BBAdjudication#paidtoprovider * total[adjudicationamounttype][3].category.text = "Amount Paid to Provider" * total[adjudicationamounttype][3].amount.value = 350.00 * total[adjudicationamounttype][3].amount.currency = #USD * item[0].productOrService = ADADentalProcedureCode#D1110 "Prophylaxis - Adult" * item[0].sequence = 1 * item[0].servicedDate = "2021-03-18" * item[0].locationCodeableConcept = $CMSPlaceofServiceCodes#11 "Office" * item[0].adjudication[adjudicationamounttype][0].category = $HL7AdjudicationCS#submitted * item[0].adjudication[adjudicationamounttype][0].amount.value = 190.00 * item[0].adjudication[adjudicationamounttype][0].amount.currency = #USD * item[0].adjudication[benefitpaymentstatus][0].category = C4BBPayerAdjudicationStatus#innetwork * item[1].productOrService = ADADentalProcedureCode#D0120 "Periodic oral evaluation" * item[1].sequence = 2 * item[1].servicedDate = "2021-03-18" * item[1].locationCodeableConcept = $CMSPlaceofServiceCodes#11 "Office" * item[1].adjudication[adjudicationamounttype][0].category = $HL7AdjudicationCS#submitted * item[1].adjudication[adjudicationamounttype][0].amount.value = 220.00 * item[1].adjudication[adjudicationamounttype][0].amount.currency = #USD * item[1].adjudication[benefitpaymentstatus][0].category = C4BBPayerAdjudicationStatus#innetwork * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2021-03-18 * supportingInfo[clmrecvddate].sequence = 3 * supportingInfo[servicefacility].category = C4BBSupportingInfoType#servicefacility * supportingInfo[servicefacility].sequence = 4 * supportingInfo[servicefacility].valueReference = Reference(OrganizationProvider1) * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "PATIENTACCTNO3" * supportingInfo[patientaccountnumber].sequence = 5 Instance: EOBOral2 InstanceOf: C4BBExplanationOfBenefitOral Description: "EOB Oral Example 2" Usage: #example * id = "EOBOral2" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitOral) * meta.lastUpdated = "2021-10-28T10:23:00-05:00" * language = #en-US * status = #active * identifier.type = $C4BBIdentifierTypeCS#uc * identifier.value = "210300012" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#oral * type.text = "Oral" * use = #claim * created = "2021-10-28T10:23:00-05:00" * insurer = Reference(OrganizationDentalPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2021-10-01" * billablePeriod.end = "2021-10-31" * provider = Reference(PractitionerDentalProvider1) * provider.display = "XXX Dental Plan" * outcome = #complete * insurance[+].focal = true * insurance[=].coverage[0] = Reference(CoverageDental1) * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[renderingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#renderingnetworkcontractingstatus * adjudication[renderingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[benefitpaymentstatus].category = C4BBAdjudicationDiscriminator#benefitpaymentstatus * adjudication[benefitpaymentstatus].reason = C4BBPayerAdjudicationStatus#innetwork * total[adjudicationamounttype][+].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][=].category.text = "Submitted Amount" * total[adjudicationamounttype][=].amount.value = 150.00 * total[adjudicationamounttype][=].amount.currency = #USD * total[adjudicationamounttype][+].category = $HL7AdjudicationCS#benefit * total[adjudicationamounttype][=].category.text = "Benefit Amount" * total[adjudicationamounttype][=].amount.value = 110.00 * total[adjudicationamounttype][=].amount.currency = #USD * total[adjudicationamounttype][+].category = C4BBAdjudication#discount * total[adjudicationamounttype][=].category.text = "Discount Amount" * total[adjudicationamounttype][=].amount.value = 40.00 * total[adjudicationamounttype][=].amount.currency = #USD * total[adjudicationamounttype][+].category = C4BBAdjudication#paidtoprovider * total[adjudicationamounttype][=].category.text = "Amount Paid to Provider" * total[adjudicationamounttype][=].amount.value = 100.00 * total[adjudicationamounttype][=].amount.currency = #USD * item[0].sequence = 1 * item[0].informationSequence[+] = 6 * item[0].informationSequence[+] = 7 * item[0].informationSequence[+] = 9 * item[0].informationSequence[+] = 10 * item[0].informationSequence[+] = 11 * item[0].productOrService = ADADentalProcedureCode#D0220 "Intraoral - periapical first radiographic image" * item[0].bodySite = ADAAreaOfOralCavitySystem#10 "Upper right quadrant" * item[0].subSite[+] = C4BBSurfaceCodes#O * item[0].subSite[+] = C4BBSurfaceCodes#I * item[0].servicedDate = "2021-10-28" * item[0].locationCodeableConcept = $CMSPlaceofServiceCodes#11 "Office" * item[0].adjudication[adjudicationamounttype][+].category = $HL7AdjudicationCS#submitted * item[0].adjudication[adjudicationamounttype][=].amount.value = 150.00 * item[0].adjudication[adjudicationamounttype][=].amount.currency = #USD * item[0].adjudication[benefitpaymentstatus][0].category = C4BBPayerAdjudicationStatus#innetwork * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2021-03-18 * supportingInfo[clmrecvddate].sequence = 3 * supportingInfo[servicefacility].category = C4BBSupportingInfoType#servicefacility * supportingInfo[servicefacility].sequence = 4 * supportingInfo[servicefacility].valueReference = Reference(OrganizationProvider1) * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "PATIENTACCTNO3" * supportingInfo[patientaccountnumber].sequence = 6 * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "PATIENTACCTNO3" * supportingInfo[patientaccountnumber].sequence = 7 * supportingInfo[patientaccountnumber].category = C4BBSupportingInfoType#patientaccountnumber * supportingInfo[patientaccountnumber].valueString = "PATIENTACCTNO3" * supportingInfo[patientaccountnumber].sequence = 8 * supportingInfo[additionalbodysite][+].category = C4BBSupportingInfoType#additionalbodysite * supportingInfo[additionalbodysite][=].code = ADAUniversalNumberingSystem#1 * supportingInfo[additionalbodysite][=].sequence = 9 * supportingInfo[additionalbodysite][+].category = C4BBSupportingInfoType#additionalbodysite * supportingInfo[additionalbodysite][=].code = ADAUniversalNumberingSystem#2 * supportingInfo[additionalbodysite][=].sequence = 10 Instance: EOBPharmacy1 InstanceOf: C4BBExplanationOfBenefitPharmacy Description: "EOB PHarmacy Example1" Usage: #example * id = "EOBPharmacy1" //* id = "1234-234-1243-12345678901-20190101-20191031" //* meta.profile = Canonical(C4BBExplanationOfBenefitPharmacy) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * status = #active * identifier.type = $C4BBIdentifierTypeCS#uc * identifier.value = "AW123412341234123412341234123412" * identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier" * type = $HL7ClaimTypeCS#pharmacy * type.text = "Pharmacy" * use = #claim * created = "2019-07-02T00:00:00+00:00" * insurer = Reference(OrganizationPayer1) * insurer.display = "XXX Health Plan" * patient = Reference(Patient1) * billablePeriod.start = "2019-10-30" * billablePeriod.end = "2019-10-31" * provider = Reference(OrganizationProvider1) * provider.display = "XXX Health Plan" * outcome = #partial * insurance[0].focal = true * insurance[0].coverage[0] = Reference(Coverage1) * adjudication[billingnetworkcontractingstatus].category = C4BBAdjudicationDiscriminator#billingnetworkcontractingstatus * adjudication[billingnetworkcontractingstatus].reason = C4BBPayerAdjudicationStatus#contracted * adjudication[benefitpaymentstatus].category = C4BBAdjudicationDiscriminator#benefitpaymentstatus * adjudication[benefitpaymentstatus].reason = C4BBPayerAdjudicationStatus#innetwork * total[adjudicationamounttype][0].category = $C4BBAdjudicationCS#paidtoprovider * total[adjudicationamounttype][0].category.text = "Payment Amount" * total[adjudicationamounttype][0].amount.value = 620.00 * total[adjudicationamounttype][0].amount.currency = #USD * total[adjudicationamounttype][1].category = $HL7AdjudicationCS#submitted * total[adjudicationamounttype][1].category.text = "Submitted Amount" * total[adjudicationamounttype][1].amount.value = 2650.00 * total[adjudicationamounttype][1].amount.currency = #USD * total[adjudicationamounttype][2].category = $C4BBAdjudicationCS#paidbypatient * total[adjudicationamounttype][2].category.text = "Patient Pay Amount" * total[adjudicationamounttype][2].amount.value = 0.00 * total[adjudicationamounttype][2].amount.currency = #USD //* adjudication[benefitpaymentstatus].category = C4BBAdjudication#other * item[0].productOrService = $FDANationalDrugCode#0777-3105-02 "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)" * item[0].sequence = 1 * item[0].servicedDate = "2019-07-02" * item[0].adjudication[adjudicationamounttype][0].category = $HL7AdjudicationCS#submitted * item[0].adjudication[adjudicationamounttype][0].amount.value = 1000.00 * item[0].adjudication[adjudicationamounttype][0].amount.currency = #USD * item[0].adjudication[adjudicationamounttype][1].category = $HL7AdjudicationCS#benefit * item[0].adjudication[adjudicationamounttype][1].amount.value = 20.00 * item[0].adjudication[adjudicationamounttype][1].amount.currency = #USD * item[0].adjudication[adjudicationamounttype][2].category = $C4BBAdjudicationCS#discount * item[0].adjudication[adjudicationamounttype][2].amount.value = 900.00 * item[0].adjudication[adjudicationamounttype][2].amount.currency = #USD * item[0].adjudication[adjudicationamounttype][3].category = $C4BBAdjudicationCS#memberliability * item[0].adjudication[adjudicationamounttype][3].amount.value = 80.00 * item[0].adjudication[adjudicationamounttype][3].amount.currency = #USD * item[0].adjudication[adjudicationamounttype][4].category = $C4BBAdjudicationCS#paidtoprovider * item[0].adjudication[adjudicationamounttype][4].amount.value = 20.00 * item[0].adjudication[adjudicationamounttype][4].amount.currency = #USD * supportingInfo[brandgenericindicator].category = C4BBSupportingInfoType#brandgenericindicator * supportingInfo[brandgenericindicator].sequence = 2 * supportingInfo[brandgenericindicator].code = NCPDPBrandGenericIndicator#2 * supportingInfo[rxoriginCode].category = C4BBSupportingInfoType#rxorigincode * supportingInfo[rxoriginCode].code = NCPDPPrescriptionOriginCode#1 * supportingInfo[rxoriginCode].sequence = 3 * supportingInfo[refillNum].category = C4BBSupportingInfoType#refillnum * supportingInfo[refillNum].valueQuantity.value = 0.0 * supportingInfo[refillNum].sequence = 4 * supportingInfo[refillsAuthorized].category = C4BBSupportingInfoType#refillsauthorized * supportingInfo[refillsAuthorized].valueQuantity.value = 0.0 * supportingInfo[refillsAuthorized].sequence = 5 * supportingInfo[dawcode].category = C4BBSupportingInfoType#dawcode * supportingInfo[dawcode].code = NCPDPDispensedAsWrittenOrProductSelectionCode#7 * supportingInfo[dawcode].sequence = 6 * supportingInfo[clmrecvddate].category = C4BBSupportingInfoType#clmrecvddate * supportingInfo[clmrecvddate].timingDate = 2019-10-31 * supportingInfo[clmrecvddate].sequence = 7 * supportingInfo[dayssupply].category = C4BBSupportingInfoType#dayssupply * supportingInfo[dayssupply].sequence = 8 * supportingInfo[dayssupply].valueQuantity.value = 30.0 * supportingInfo[compoundcode].category = C4BBSupportingInfoType#compoundcode * supportingInfo[compoundcode].code = NCPDPCompoundCode#Dummy * supportingInfo[compoundcode].sequence = 9 Instance: OrganizationPayer1 InstanceOf: C4BBOrganization Description: "Payer1" Usage: #example * id = "Payer1" //* meta.profile = Canonical(C4BBOrganization) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * identifier[NPI].type = $HL7IdentifierType#NPI * identifier[NPI].value = "345678" * identifier[payerid].type = $C4BBIdentifierTypeCS#payerid * identifier[payerid].value = "901234" * name = "Payer 1" * active = true Instance: OrganizationDentalPayer1 InstanceOf: C4BBOrganization Description: "Dental Payer1" Usage: #example * id = "OrganizationDentalPayer1" //* meta.profile = Canonical(C4BBOrganization) * meta.lastUpdated = "2021-01-01T10:23:11+00:00" * language = #en-US * identifier[NPI].type = $HL7IdentifierType#NPI * identifier[NPI].value = "467678" * identifier[payerid].type = $C4BBIdentifierTypeCS#payerid * identifier[payerid].value = "66783JJT" * name = "INSURANCE COMPANY XYZ" * active = true Instance: OrganizationProvider1 InstanceOf: C4BBOrganization Description: "Provider 1" Usage: #example //* meta.profile = Canonical(C4BBOrganization) * meta.lastUpdated = "2019-12-12T09:14:11+00:00" * language = #en-US * identifier[NPI].type = $HL7IdentifierType#NPI * identifier[NPI].value = "345678" * identifier[tax].type = $IdentifierType#TAX * identifier[tax].value = "123-45-6789" * name = "Provider 1" * active = true Instance: PractitionerDentalProvider1 InstanceOf: C4BBPractitioner Description: "Dental Provider 1" Usage: #example //* meta.profile = Canonical(C4BBOrganization) * meta.lastUpdated = "2021-01-01T10:23:11+00:00" * language = #en-US * identifier[NPI].type = $HL7IdentifierType#NPI * identifier[NPI].value = "0025501002" * name[0].family = "Schmidt" * name[0].given[0] = "Stewart" * name[0].suffix = "DDS" * active = true Instance: PractitionerProvider1 InstanceOf: C4BBPractitioner Description: "Provider 1" Usage: #example //* meta.profile = Canonical(C4BBOrganization) * meta.lastUpdated = "2022-07-27T10:23:11+00:00" * language = #en-US * identifier[NPI].type = $HL7IdentifierType#NPI * identifier[NPI].value = "846274937" * name[0].family = "Levin" * name[0].given[0] = "Henry" * name[0].suffix = "MD" * active = true