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 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Change Notes

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) was developed under the CARIN Alliance.

Changes and Updates for Version 2.0.0 (from version 1.1.0)

The current official published version of CARIN BB for FHIR R4

• Added Oral ExplanationOfBenefit profile and vision type to Professional NonClinician ExplanationOfBenefit profile (FHIR-34009, FHIR-27025, FHIR-37706, FHIR-37562, and FHIR-35146)
  • Added orthodontics and prosthesis to Supporting Info Type ValueSet used as a discriminator for the EOB Oral profile supportingInfo slice discriminator (FHIR-34010)
  • Added US Surface Codes for Oral ExplanationOfBenefit.item.subSite (FHIR-34089)
  • Added Invariants requiring all ExplanationOfBenefit.supportingInfo[additionalBodySite] instances be referred to by at least one ExplanationOfBenefit.item and require a tooth number for line items where a surface code in ExplanationOfBenefit.item.subsite exists in Oral ExplanationOfBenefit profile (FHIR-34091)
• Changed cardinality of ExplanationOfBenefit.item from 0..* to 1..* in Base ExplanationOfBenefit profile requiring ExplanationOfBenefit for all all Resource ExplanationOfBenefit profiles (FHIR-34114) *
• Require item.location[x] to be only CodeableConcept in Professional and Oral ExplanationOfBenefit profiles (FHIR-32067) *
• Changed Professional NonClinician ExplanationOfBenefit item.location[x] from cardinality of 0..1 to 1..1 and added Must Support (FHIR-34148) *
• Changed item.serviced[x] and billablePeriod cardinality (FHIR-31639 and FHIR-36760) *
  • ExplanationOfBenefit.item.serviced[x] from 0..1 to 1..1 and billablePeriod from 0..1 to 1..1 for Outpatient Institutional ExplanationOfBenefit profile
  • ExplanationOfBenefit.item.serviced[x] and ExplanationOfBenefit.billablePeriod from 0..1 to 1..1 for Professional NonClinician ExplanationOfBenefit profile
  • ExplanationOfBenefit.item.serviced[x] from 0..1 to 1..1 for Pharmacy ExplanationOfBenefit profile
• Changed the Pharmacy Explanation Of Benefit profile serviced[x] to only be a date (FHIR-38668) *
• Added Must Support to ExplanationOfBenefit.item.serviced[x] leaf elements on the Outpatient Institutional and Professional NonClinician ExplanationOfBenefit profiles (FHIR-38669) *
• Moved ExplanationOfBenefit.total[benefitpaymentstatus] slice to ExplanationOfBenefit.adjudication[benefitpaymentstatus] (therefore not requiring an amount property) for Inpatient Institutional, Outpatient Institutional, Pharmacy, and Oral ExplanationOfBenefit profiles, changed the pattern to match other adjudication repetitions, and update the invariants appropriately(FHIR-33082, FHIR-37726, FHIR-38063, and FHIR-35358) *
• Changed codes term of "performing" provider to "rendering" provider in the Claim Care Team Role and Adjudication Discriminator CodeSystems and in Oral ExplanationOfBenefit and Professional NonClinician ExplanationOfBenefit profiles rendering provider network status (FHIR-37727) *
• Changed rendering network status from ExplanationOfBenefit.supportingInfo slice to ExplanationOfBenefit.adjudication slice in Oral ExplanationOfBenefit and Professional NonClinician ExplanationOfBenefit profiles and changed billing network status ExplanationOfBenefit.supportingInfo slice to ExplanationOfBenefit.adjudication slice in all non-abstract ExplanationOfBenefit profiles (FHIR-37728) *
• Changed provider "contracting network status" to provider "network status" by updating Adjudication Discriminator; changing the C4BBPayerProviderContractingStatus ValueSet to C4BBPayerProviderNetworkStatus ValueSet with `innetwork` and `outofnetwork` codes; removing "contracted" and "notcontracted" codes in Payer Adjudication Status ValueSet, and updating the `innetwork` and `outofnetwork` code definitions for applicability for the provider network status (FHIR-38059) *
• Updated the definition of Must Support to state "Health Plan API actors SHALL be capable of populating all data elements the payer maintains" which are marked as Must Support, and remove the requirement that "Consumer App actors SHOULD be capable of storing the information for other purposes" (FHIR-36675 and FHIR-35730)
• Changed ExplanationOfBenefit.adjudication and ExplanationOfBenefit.item.adjudication slicing from closed to open for all Resource ExplanationOfBenefit profiles (FHIR-34241)
• Add not-applicable code to Professional Procedure Codes ValueSet and Oral Procedure Code ValueSet for Professional NonClinician ExplanationOfBenefit profile (with Invariant allowing only if type = vision) and Oral (ExplanationOfBenefit.item.productOrService) (FHIR-33024)
• Removed Invariant that not allowing not-applicable code for Outpatient Institutional ExplanationOfBenefit profile item.productOrService (FHIR-32850)
• Changed Practitioner and Organization profiles identifier.type in the NPI slice to use the `NPI` from CodeSystem http://terminology.hl7.org/CodeSystem/v2-0203 (FHIR-35712) *
• Updated the Base Explanation Of Benefit profile to require the identifier to contain the unique claim id (FHIR-38660) *
• Added Non-emergency transport information to ExplanationOfBenefit.supportingInfo slices to the Professional NonClinician ExplanationOfBenefit profile along with invariant rules (FHIR-37615)
• Removed meta.profile requirements on Abstract base ExplanationOfBenefit profile (FHIR-34504)
• Added refillsAuthorized slice to ExplanationOfBenefit.supportingInfo of Pharmacy ExplanationOfBenefit profile (FHIR-33487)
• Changed payee.party cardinality from 1..1 to 0..1 and added invariant requiring payee.party if payee.type='other' in Base ExplanationOfBenefit profile and added new RelatedPerson profile as a reference option (FHIR-31699 and FHIR-37740)
• Added service-start-date search parameter and billable-period-start search parameter (FHIR-33165 and FHIR-34428)
• Added _id search parameter for all resources and change conformance expectation for Practitioner and Organization resources to SHOULD to allow for them to be supported as contained resources in Capability Statement with associated guidance and related the resources' meta.lastUpdated requirement (FHIR-38108 and FHIR-36676)
• Added guidance on the expectation of _include support and interpretation of _include=ExplanationOfBenefit:* to search Parameters page and Capability Statement including adding ExplanationOfBenefit:payee (FHIR-32982)
• Added a requirement in the General Guidance that servers SHALL include a CapabilityStatement that has a CapabilityStatement.instantiates specifying the CapabilityStatement in this specification (FHIR-35360)
• Updated the CapabilityStatement security section allowing unauthorized requests responses of HTTP 403 "Forbidden" or HTTP 404 "Not Found" in addition to the previously stated HTTP 401 "Unauthorized" (FHIR-35766)
• Moved ExplanationOfBenefit searches documentation from read interaction to search-type interaction in Capability Statement (FHIR-33176)
• Removed invalid invariant from Professional NonClinician ExplanationOfBenefit profile that required ExplanationOfBenefit.careTeam.provider to be an Organization reference when careTeam.role was 'site' ('site' not a code in the role ValueSet) (FHIR-31658)
• Corrected invalid invariant for the CareTeam qualification being from a specific CodeSystem when the type is rendering in the Abstract base ExplanationOfBenefit profile (FHIR-35889)
• Added paidbypatientcash, paidbypatientother, paidbypatienthealthaccount codes to Adjudication ValueSet and Adjudication CodeSystem (FHIR-33996 and FHIR-37831)
• Updated the url for the HCPCS Level II codes in C4BBEOBInstitutionalProcedureCodes (FHIR-37334)
• Removed the fixed meta.profile slice requirement including the full version and replaced with invariant requirements requiring a meta.profile with the major and minor version included in all non-abstract ExplanationOfBenefit profiles (to allow instances from different patch versions to still validate) (FHIR-34223)
• Updated from US Core 3.1.0 to 3.1.1. (FHIR-33177 and FHIR-35708)
• Modified security guidance in Security and Privacy Considerations page (FHIR-31693, FHIR-35729 and FHIR-35722)
• Changed display of code other from default value of "Provider to "Other" in Payee Type ValueSet (FHIR-34020)
• Added guidance for the use of the 11-digit NDC code for Pharmacy ExplanationOfBenefit profile item.productOrService and item.detail.productOrService (FHIR-32660)
• Corrected XPath expression for the service-date SearchParameter (FHIR-32843)
• Corrected invariant for Inpatient Institutional and Outpatient Institutional ExplanationOfBenefit profiles to allow other adjudication slices that do not have a category.code from C4BBAdjudication ValueSet (adjudicationamounttype slice) (FHIR-32978)
• Removed second extra repetition of meta.profile on all examples (FHIR-32428)
• Added clearer guidance on ExplanationOfBenefit.supportingInfo[servicefacility] and ExplanationOfBenefit.item.location[x] to Professional NonClinician ExplanationOfBenefit profile; ExplanationOfBenefit.item.location[x] and ExplanationOfBenefit.supportingInfo[typeofbill] to Inpatient Institutional and Outpatient Institutional ExplanationOfBenefit profiles (FHIR-34087)
• Removed references to PractitionerRole and Location from Background Relation to other IGs section (FHIR-33060)
• Added clearer description of ExplanationOfBenefit.related for Base ExplanationOfBenefit profile (FHIR-31411)
• Removed CodeSystems that were duplicative of those identified in terminology.hl7.org (THO). These removals are non-substantive as they do not change the CodeSystem url used in resource instance communication (FHIR-38285)
• Updated element short descriptions to be more meaningful for all all Resource profiles (FHIR-34091)
• Add guidance to the General Guidance section providing more information on considerations payers and consumer apps should make for understanding improving rendering of the Explanation Of Benefit data. A example explanation of benefit document with mapping to CPCDS data elements and profile paths is provided to assist consumer app developers in understanding the data elements and suggesting how payers might improve their API documentation for connecting system developers (FHIR-31069)
• Updated diagrams and CPCDS resources to match the changes on the latest version of this specification and added comparison of Explanation of Benefit dates (FHIR-35212, FHIR-34513, and FHIR-38661)
• Remove Must Support from Patient.address.district in the Patient profile (FHIR-35710)
• Added a note for implementers to all locally defined CodeSystems that may switch the to central terminology.hl7.org (THO) that the code system is subject to change in a future version (FHIR-37830)
• Added guidance regarding the definition of the payer id identifier to the Identifier Type CodeSystem and the Organization profile identifier payerid slice (FHIR-36771 and FHIR-36770)
• Made navigation and title updates FHIR-38692)
• Removed broken link reference to "API Resource Collection in Health (ARCH)" from the General Guidance page (FHIR-35956)

Changes and Updates for Version 1.1.0

STU Update of STU 1

• Added Data Absent Reason "not-applicable" code to Institutional Procedure Codes ValueSet for use with Inpatient Institutional EOB item.productOrService and an Invariant disallowing the use of this code in Outpatient Institutional EOB (FHIR-30357)
• Changed Inpatient Institutional EOB supportingInfo DRG code terminology binding strength from required to extensible to allow for state Medicaid assigned DRGs (FHIR-30380)
• Added HIPPS codes to Institutional EOB Procedure Codes ValueSet (FHIR-30413)
• Added C4BB Payer Benefit Payment Status to C4BB Adjudication Category Discriminator ValueSet for use in the Professional and NonClinician EOB item.adjudication and removed inoutnetwork code from Adjudication Discriminator CodeSystem (FHIR-30806)
• Changes on differentiating ExplanationOfBenefit profiles (FHIR-31594) *
  • Added ExplanationofBenefit.subType requirements to the Inpatient and Outpatient Institutional ExplanationOfBenefit profiles.
  • Added Institutional Claim Subtype ValueSet and Institutional Claim Subtype CodeSystem
• Changed resources used to present patient account number and medical record number (FHIR-31534) *
  • Removed medrecnum and patacctnum slices from the Patient profile Patient.Identifier
  • Added medicalrecordnumber and patientaccountnumber supportingInfo slices to Inpatient, Outpatient, and Professional Non-Clinical ExplanationOfBenefit profiles
  • Added medicalrecordnumber and patientaccountnumber to Supporting Info Type CodeSystem
• Added NUBC Point of Origin for Newborn CodeSystem and renamed NUBC Point of Origin CodeSystem to NUBC Point of Origin for Non-newborn CodeSystem for Inpatient and Outpatient Institutional EOB supportingInfo Point of Origin ValueSet for use when Type of Admission is newborn, Inpatient Institutional EOB Invariant, and Outpatient Institutional EOB Invariant (FHIR-30370 and FHIR-31384) *
• Added Invariants requiring adjudication[adjudicationamounttype] and adjudication[adjudicationamounttype].amount when header level adjudication is present to Inpatient and Outpatient Institutional EOBs and changed Professional and NonClinician EOB total[adjudicationamounttype] to a cardinality of 1..*( Changed item.adjudication[adjudicationamounttype].amount (FHIR-30369) *
• Changes of requirements and guidance on all profiles meta.profile (FHIR-30375) *
  • Defined fixed values for a slice of meta.profile for all profiles.
  • Added guidance on the use of meta.profile as notes to all profiles.
• Updated NCPDP CodeSystem URLs (FHIR-31492) * including:
  • NCPDP Brand Generic Indicator
  • NCPDP Compound Code
  • NCPDP Dispense As Written (DAW)/Product Selection Code
  • NCPDP Prescription Origin Code
  • NCPDP Reject Code
• Changed inoutnetwork slice names and cardinalities (FHIR-30635), and Move total [benefitpaymentstatus] slice to supportingInfo (FHIR-33082) *
  • Changed Inpatient Institutional, Outpatient Institutional, and Pharmacy EOBs total[inoutnetwork] slice name to benefitpaymentstatus
  • Changed Professional and NonClinician EOB item.adjudication[inoutnetwork] slice name to benefitpayementstatus
  • Changed cardinality of Inpatient and Outpatient Institutional EOB supportingInfo[benefitpaymentstatus] from (0..1) to (1..1)
  • Removed notes in Professional and NonClinician EOB referencing total[inoutnetwork] slice name
  • Updated notes for all profiles that referenced inoutnetwork slice name to benefitpaymentstatus
  • Updated the Detailed Profile Comparison image and source file (xslx) in section 5
• Changed cardinality of several slice properties from (0..1) to (1..1) (FHIR-30807) *
  • Changed cardinality of item.adjudication[allowedunits].value from (0..1) to (1..1) in Inpatient and Outpatient Institutional EOBs
  • Changed Inpatient Institutional EOB adjudication[denialreason].reason cardinality from (0..1) to (1.1.)
  • Changed Outpatient Institutional EOB supportingInfo[pointoforigin].code cardinality from (0..1) to (1..1)
• Added 'Must Support' to Professional and NonClinician EOB item.productOrService and item.modifier (FHIR-30358)
• Fixed Explanations of Benefits Profile Definition diagram and source presentation file (pptx) legend and added DRG owner (FHIR-30360)
• Changed Inpatient EOB insurance cardinality for 1..1 to 1..* by removing constraint in profile (FHIR-31477)
• Removed IG specified requirements of Coverage.Subscriber from the Coverage Profile (FHIR-31535)
• Removed incorrect casting of ExplanationOfBenefit service-date (item.serviced) search parameter (FHIR-30443))
• Added language regarding security and privacy to the Authorization, Authentication, and Registration page with a link to the HL7 FHIR Security and Privacy Module (FHIR-31692)
• Shortened the titles of Inpatient Institutional, Outpatient Institutional, and Professional and NonClinician EOB Procedure Code and Procedure Code Modifier ValueSets (FHIR-31074)
• Fixed errors in examples
  • Inpatient and Outpatient Institutional EOB examples, removed top-level adjudication because item level adjudication was present (FHIR-29802)
  • Fixed incorrect text in EOB Professional example (FHIR-30372)
• Added missing Diagram in How DaVinci’s PDex IG and the CARIN IG for Blue Button® work together (FHIR-30083)
• Added additional contributors (FHIR-30084)
• Transitioned project structure for Sushi 1.0.0+ (For Implementation Guide generation)
• Corrected link to 3M licensing information https://jira.hl7.org/browse/FHIR-31066
• Updated the Server CapabilityStatement Persuasive with Mod, Add _id to Coverage Search parameters in CapabilityStatement https://jira.hl7.org/browse/FHIR-30009
• Added Tighter guidance requiring WHEN provenance in the EOB profileshttps://jira.hl7.org/browse/FHIR-31639
• Removed the invariant referring to careTeam role "site" from the IGhttps://jira.hl7.org/browse/FHIR-31658
• Increased binding strength for place of service codeshttps://jira.hl7.org/browse/FHIR-31502
• Added more granular date searching with additional search parametershttps://jira.hl7.org/browse/FHIR-33165
• Removed Invariant disallowing not-applicable from Outpatient Institutional EoB item.productOrServicehttps://jira.hl7.org/browse/FHIR-32850
• Change item.location[x] to only locationCodeableConcept https://jira.hl7.org/browse/FHIR-32067

Note: Items marked with an “*” are non-compatible with earlier versions - Existing data may not be valid against the new specification.