CARIN Consumer Directed Payer Data Exchange
0.1.3 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.1.3). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOBInpatient1 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBInpatient1"/>
  <meta>
    <lastUpdated value="2019-12-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"/>
  </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><b>Generated Narrative</b></p><h3>Ids</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><h3>Meta</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>language</b>: en-US</p><p><b>identifier</b>: Claim Number: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}">Inpatient Institution</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-Patient1.html">Generated Summary: language: en-US; Member ID: 1234-234-1243-12345678901, Medical record number: 1234-234-1243-12345678901m, Unique Member ID: 1234-234-1243-12345678901u, Patient Account Number: 1234-234-1243-12345678901a; active; Johnny Example1 ; ph: (301)666-1212; gender: male; birthDate: 1986-01-01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></a></p><p><b>billablePeriod</b>: Jan 1, 2019, 12:00:00 AM --&gt; Oct 31, 2019, 12:00:00 AM</p><p><b>created</b>: Jul 2, 2019, 12:00:00 AM</p><p><b>insurer</b>: <a href="Organization-OrganizationPayer1.html">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Payer ID: 901234; active; name: Payer 1</a></p><p><b>provider</b>: <a href="Organization-OrganizationProvider1.html">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Tax ID number: 123-45-6789; active; name: Provider 1</a></p><p><b>outcome</b>: partial</p><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td><span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm S06.0x1A}">S06.0x1A</span></td><td><span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType principal}">Principal</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-Coverage1.html">Generated Summary: language: en-US; Member ID: 1234-234-1243-12345678901; status: active; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span>; subscriberId: 12345678901; dependent: 01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span>; period: Jan 1, 2019, 12:00:00 AM --&gt; Oct 31, 2019, 12:00:00 AM; network: XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}">Payment Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidbypatient}">Patient Pay Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication innetwork}">In-network</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS"/>
        <code value="cn"/>
      </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="Inpatient Institution"/>
  </type>
  <use value="claim"/>
  <patient>
    <reference value="Patient/Patient1"/>
  </patient>
  <billablePeriod>
    <start value="2019-01-01T00:00:00+00:00"/>
    <end value="2019-10-31T00:00:00+00:00"/>
  </billablePeriod>
  <created value="2019-07-02T00:00:00+00:00"/>
  <insurer>
    <reference value="Organization/OrganizationPayer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>
    <reference value="Organization/OrganizationProvider1"/>
    <display value="XXX Health Plan"/>
  </provider>
  <outcome value="partial"/>
  <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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/Coverage1"/>
    </coverage>
  </insurance>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Payment Amount"/>
    </category>
    <amount>
      <value value="620"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="2650"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidbypatient"/>
      </coding>
      <text value="Patient Pay Amount"/>
    </category>
    <amount>
      <value value="0"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="innetwork"/>
      </coding>
    </category>
    <amount>
      <value value="0"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>