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 Outpatient Institutional - Example 2

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBOutpatient2" Updated "2020-10-13 11:10:24-0400"

Information Source: Organization/PayerOrganizationExample1!

Profile: C4BB ExplanationOfBenefit Outpatient 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: OutpatientEOBExample1

status: active

type: Institutional (Claim Type Codes#institutional)

subType: Outpatient (C4BB Institutional Claim SubType Code System#outpatient)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2020-09-29 --> 2020-09-29

created: 2020-10-10 12:00:00-0400

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

provider: Organization/ProviderOrganization5 "Black Medical Group"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider")Organization/ProviderOrganization6 "White Medical Group"

outcome: complete

careTeam

sequence: 1

provider: Practitioner/Practitioner1 " SMITH"

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

careTeam

sequence: 2

provider: Practitioner/Practitioner3 " WILLIAMS"

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

SupportingInfos

-SequenceCategoryTiming[x]
*1Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)2020-10-10

diagnosis

sequence: 1

diagnosis: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)

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: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)

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

diagnosis

sequence: 3

diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#L97.529)

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

diagnosis

sequence: 4

diagnosis: Peripheral vascular disease, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I73.9)

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

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

revenue: 0551 (AHA NUBC Revenue Codes#0551)

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

serviced: 2020-09-29

location: HOME (CMS Place of Service Codes (POS)#12)

adjudication

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

Amounts

-ValueCurrency
*84.4USD

adjudication

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

Amounts

-ValueCurrency
*0USD

adjudication

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

Amounts

-ValueCurrency
*56.52USD

adjudication

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

Amounts

-ValueCurrency
*0USD

adjudication

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

Amounts

-ValueCurrency
*56.52USD

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")

Amounts

-ValueCurrency
*0USD

item

sequence: 2

revenue: 0023 (AHA NUBC Revenue Codes#0023)

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

serviced: 2020-09-29

location: HOME (CMS Place of Service Codes (POS)#12)

adjudication

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

Amounts

-ValueCurrency
*0USD

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")

Amounts

-ValueCurrency
*0USD

Adjudications

-CategoryReason
*Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)In Network (C4BB Payer Adjudication Status Code System#innetwork)

total

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

Amounts

-ValueCurrency
*56.52USD

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
*0USD

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
*56.52USD

total

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

Amounts

-ValueCurrency
*0USD

Notes:

Instance: EOBOutpatient2
InstanceOf: ExplanationOfBenefit
Title: "EOB Outpatient Institutional - Example 2"
Description: "EOB Outpatient Institutional - Example 2"
Usage: #example
* meta.lastUpdated = "2020-10-13T11:10:24-04:00"
* meta.source = "Organization/PayerOrganizationExample1"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-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 = "OutpatientEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
  * text = "Institutional"
* subType = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType#outpatient
  * text = "Outpatient"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2020-09-29"
* billablePeriod.end = "2020-09-29"
* created = "2020-10-10T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization5)
* 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(ProviderOrganization6)
* outcome = #complete
* careTeam[0].sequence = 1
* careTeam[=].provider = Reference(Practitioner1)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#attending "Attending"
  * text = "The attending physician"
* careTeam[+].sequence = 2
* careTeam[=].provider = Reference(Practitioner3)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#referring "Referring"
  * text = "The referring physician"
* supportingInfo.sequence = 1
* supportingInfo.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo.timingDate = "2020-10-10"
* diagnosis[0].sequence = 1
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I95.1
* 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#I95.1
* 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#L97.529
* 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#I73.9
* 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"
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0551
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedDate = "2020-09-29"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#12
  * text = "HOME"
* item[=].adjudication[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* item[=].adjudication[=].category.text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 84.4
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#copay "CoPay"
  * text = "Patient Co-Payment"
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
  * text = "Amount of the change which is considered for adjudication."
* item[=].adjudication[=].amount.value = 56.52
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
  * text = "Amount deducted from the eligible amount prior to adjudication."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
  * text = "Amount payable under the coverage"
* item[=].adjudication[=].amount.value = 56.52
* item[=].adjudication[=].amount.currency = #USD
* item[=].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."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 2
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0023
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedDate = "2020-09-29"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#12
  * text = "HOME"
* item[=].adjudication[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* item[=].adjudication[=].category.text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].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."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* adjudication.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication.reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* total[=].category.text = "Amount of the change which is considered for adjudication."
* total[=].amount.value = 56.52
* 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 = 0
* 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 = 56.52
* 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