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 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

Example ExplanationOfBenefit: EOB Inpatient Example 2

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBInpatient2" Updated "2020-04-28 03:39:36-0400"

Profile: C4BB ExplanationOfBenefit Inpatient Institutional (version 2.0.0)

identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1

status: active

type: Institutional (Claim Type Codes#institutional)

subType: Inpatient (C4BB Institutional Claim SubType Code System#inpatient)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2017-05-23 --> 2017-05-23

created: 2017-06-01 12:00:00-0400

insurer: Organization/Payer2: UPMC Health Plan "UPMC Health Plan"

provider: Organization/ProviderOrganization3 "Green Medical Group"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider")Organization/ProviderOrganization4 "Blue Medical Group"

outcome: complete

careTeam

sequence: 1

provider: Practitioner/Practitioner2 " BROWN"

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

careTeam

sequence: 2

provider: Practitioner/Practitioner2 " BROWN"

role: The referring physician (C4BB Claim Care Team Role Code System#referring "Referring")

supportingInfo

sequence: 2

category: Admission Period (C4BB Supporting Info Type Code System#admissionperiod)

timing: 2017-05-23 --> (ongoing)

supportingInfo

sequence: 1

category: Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)

timing: 2017-06-01

diagnosis

sequence: 1

diagnosis: Non-ST elevation (NSTEMI) myocardial infarction (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I21.4)

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: Athscl heart disease of native cor art w oth ang pctrs (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I25.118)

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

diagnosis

sequence: 3

diagnosis: Hyperlipidemia, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#E78.5)

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

diagnosis

sequence: 4

diagnosis: Unspecified osteoarthritis, unspecified site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#M19.90)

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

procedure

sequence: 1

type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis (C4BB Claim Procedure Type Code System#principal "Principal")

date: 2017-05-23

procedure: 4A023N7 (ICD-10 Procedure Codes#4A023N7)

procedure

sequence: 2

type: Other procedures performed during the inpatient institutional admission (C4BB Claim Procedure Type Code System#other "Other")

date: 2017-05-23

procedure: B211YZZ (ICD-10 Procedure Codes#B211YZZ)

procedure

sequence: 3

type: Other procedures performed during the inpatient institutional admission (C4BB Claim Procedure Type Code System#other "Other")

date: 2017-05-23

procedure: B215YZZ (ICD-10 Procedure Codes#B215YZZ)

Insurances

-FocalCoverage
*trueCoverage/Coverage2

item

sequence: 1

revenue: 0301 (AHA NUBC Revenue Codes#0301)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 2

revenue: 0260 (AHA NUBC Revenue Codes#0260)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 3

revenue: 0305 (AHA NUBC Revenue Codes#0305)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 4

revenue: 0324 (AHA NUBC Revenue Codes#0324)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 5

revenue: 0259 (AHA NUBC Revenue Codes#0259)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 6

revenue: 0250 (AHA NUBC Revenue Codes#0250)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 7

revenue: 0710 (AHA NUBC Revenue Codes#0710)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 8

revenue: 0210 (AHA NUBC Revenue Codes#0210)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 9

revenue: 0272 (AHA NUBC Revenue Codes#0272)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 10

revenue: 0370 (AHA NUBC Revenue Codes#0370)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 11

revenue: 0730 (AHA NUBC Revenue Codes#0730)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 12

revenue: 0450 (AHA NUBC Revenue Codes#0450)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

item

sequence: 13

revenue: 0481 (AHA NUBC Revenue Codes#0481)

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

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)

adjudication

category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)

reason: Out Of Network (C4BB Payer Adjudication Status Code System#outofnetwork)

adjudication

category: Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus)

reason: Indicates the provider was in network for the service (C4BB Payer Adjudication Status Code System#innetwork "In Network")

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 Code System#noncovered "Noncovered")

total

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

Amounts

-ValueCurrency
*7147.2USD

total

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

Amounts

-ValueCurrency
*1542.01USD

total

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

Amounts

-ValueCurrency
*0USD

total

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

Amounts

-ValueCurrency
*120USD

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 Code System#noncovered "Noncovered")

Amounts

-ValueCurrency
*0USD

total

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

Amounts

-ValueCurrency
*1393.57USD

total

category: The amount of the member's liability. (C4BB Adjudication Code System#memberliability "Member liability")

Amounts

-ValueCurrency
*0USD

Notes:

Instance: EOBInpatient2
InstanceOf: ExplanationOfBenefit
Title: "EOB Inpatient Example 2"
Description: "EOB Inpatient Example 2"
Usage: #example
* meta.lastUpdated = "2020-04-28T15:39:36-04:00"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.0"
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc "Unique Claim ID"
  * text = "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
* identifier.system = "https://www.upmchealthplan.com/fhir/EOBIdentifier"
* identifier.value = "InpatientEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
  * text = "Institutional"
* subType = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType#inpatient
  * text = "Inpatient"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2017-05-23"
* billablePeriod.end = "2017-05-23"
* created = "2017-06-01T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization3)
* payee.type = http://terminology.hl7.org/CodeSystem/payeetype#provider "Provider"
  * text = "Any benefit payable will be paid to the provider (Assignment of Benefit)."
* payee.party = Reference(ProviderOrganization4)
* outcome = #complete
* careTeam[0].sequence = 1
* careTeam[=].provider = Reference(Practitioner2)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#attending "Attending"
  * text = "The attending physician"
* careTeam[+].sequence = 2
* careTeam[=].provider = Reference(Practitioner2)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#referring "Referring"
  * text = "The referring physician"
* supportingInfo[0].sequence = 2
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#admissionperiod
* supportingInfo[=].timingPeriod.start = "2017-05-23"
* supportingInfo[+].sequence = 1
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2017-06-01"
* diagnosis[0].sequence = 1
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I21.4
* diagnosis[=].type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal "Principal Diagnosis"
  * text = "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
* diagnosis[+].sequence = 2
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I25.118
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
  * text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+].sequence = 3
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#E78.5
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
  * text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+].sequence = 4
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#M19.90
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
  * text = "Required when other conditions coexist or develop subsequently during the treatment"
* procedure[0].sequence = 1
* procedure[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType#principal "Principal"
  * text = "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
* procedure[=].date = "2017-05-23"
* procedure[=].procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#4A023N7
* procedure[+].sequence = 2
* procedure[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType#other "Other"
  * text = "Other procedures performed during the inpatient institutional admission"
* procedure[=].date = "2017-05-23"
* procedure[=].procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#B211YZZ
* procedure[+].sequence = 3
* procedure[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType#other "Other"
  * text = "Other procedures performed during the inpatient institutional admission"
* procedure[=].date = "2017-05-23"
* procedure[=].procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#B215YZZ
* insurance.focal = true
* insurance.coverage = Reference(Coverage2)
* item[0].sequence = 1
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0301
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 2
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0260
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 3
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0305
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 4
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0324
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 5
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0259
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 6
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0250
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 7
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0710
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 8
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0210
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 9
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0272
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 10
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0370
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 11
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0730
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 12
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0450
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+].sequence = 13
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0481
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedPeriod.start = "2017-05-23"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#outofnetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork "In Network"
  * text = "Indicates the provider was in network for the service"
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#noncovered "Noncovered"
  * 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."
* adjudication[=].amount.value = 0
* adjudication[=].amount.currency = #USD
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* total[=].category.text = "The total submitted amount for the claim or group or line item."
* total[=].amount.value = 7147.2
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
  * text = "Amount of the change which is considered for adjudication."
* total[=].amount.value = 1542.01
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
  * text = "Amount deducted from the eligible amount prior to adjudication."
* total[=].amount.value = 0
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#copay "CoPay"
  * text = "Patient Co-Payment"
* total[=].amount.value = 120
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#noncovered "Noncovered"
  * 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[=].amount.value = 0
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
  * text = "Amount payable under the coverage"
* total[=].amount.value = 1393.57
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#memberliability "Member liability"
  * text = "The amount of the member's liability."
* total[=].amount.value = 0
* total[=].amount.currency = #USD