CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="BB-EOBInpatient1-nonfinancial"/>
<meta>
<lastUpdated value="2019-12-12T09:14:11+00:00"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis|2.1.0"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit BB-EOBInpatient1-nonfinancial</b></p><a name="BB-EOBInpatient1-nonfinancial"> </a><a name="hcBB-EOBInpatient1-nonfinancial"> </a><a name="BB-EOBInpatient1-nonfinancial-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2019-12-12 09:14:11+0000; Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis.html">C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: null2.1.0)</a></p></div><p><b>identifier</b>: Unique Claim ID/AW123412341234123412341234123412</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>subType</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType inpatient}">Inpatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)</a></p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-11-02 00:00:00+0000</p><p><b>insurer</b>: <a href="Organization-Payer1.html">XXX Health Plan</a></p><p><b>provider</b>: <a href="Organization-ProviderOrganization1.html">XXX Health Plan</a></p><p><b>outcome</b>: Partial Processing</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}">Admission Period</span></p><p><b>timing</b>: 2011-05-23 --> 2011-05-25</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Claim Received Date</span></p><p><b>timing</b>: 2011-05-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType typeofbill}">Type of Bill</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/TypeOfBill Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType pointoforigin}">Point Of Origin</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PointOfOrigin Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admtype}">Admission Type</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType discharge-status}">Discharge Status</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PatDischargeStatus 11}">11</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType medicalrecordnumber}">Medical Record Number</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientaccountnumber}">Patient Account Number</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.0X1A}">Concussion w LOC of 30 minutes or less, init</span></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}">Principal Diagnosis</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Coverage-Coverage3.html">Coverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --> 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes Dummy}">Dummy</span></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/data-absent-reason not-applicable}">Not Applicable</span></td><td>2019-11-02</td></tr></table><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}">Billing Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr></table></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
<code value="uc"/>
</coding>
</type>
<system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
<value value="AW123412341234123412341234123412"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
</coding>
<text value="Institutional"/>
</type>
<subType>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
<code value="inpatient"/>
</coding>
<text value="Inpatient"/>
</subType>
<use value="claim"/>
<patient>🔗
<reference value="Patient/Patient2"/>
</patient>
<billablePeriod>
<start value="2019-01-01"/>
<end value="2019-10-31"/>
</billablePeriod>
<created value="2019-11-02T00:00:00+00:00"/>
<insurer>🔗
<reference value="Organization/Payer1"/>
<display value="XXX Health Plan"/>
</insurer>
<provider>🔗
<reference value="Organization/ProviderOrganization1"/>
<display value="XXX Health Plan"/>
</provider>
<outcome value="partial"/>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="admissionperiod"/>
</coding>
</category>
<timingPeriod>
<start value="2011-05-23"/>
<end value="2011-05-25"/>
</timingPeriod>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="clmrecvddate"/>
</coding>
</category>
<timingDate value="2011-05-30"/>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="typeofbill"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="pointoforigin"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/PointOfOrigin"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="admtype"/>
</coding>
</category>
<code>
<coding>
<system
value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="7"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="discharge-status"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/PatDischargeStatus"/>
<code value="11"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="medicalrecordnumber"/>
</coding>
</category>
<valueString value="1234-234-1243-12345678901m"/>
</supportingInfo>
<supportingInfo>
<sequence value="9"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="patientaccountnumber"/>
</coding>
</category>
<valueString value="1234-234-1243-12345678901a"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.0X1A"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
</diagnosis>
<insurance>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/Coverage3"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="Dummy"/>
</coding>
</revenue>
<productOrService>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
<code value="not-applicable"/>
<display value="Not Applicable"/>
</coding>
</productOrService>
<servicedDate value="2019-11-02"/>
</item>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="benefitpaymentstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="billingnetworkstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
</ExplanationOfBenefit>
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2024-12-18
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