CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 United States of America flag

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 Professional - Example 1

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBProfessional1" Updated "2019-12-12 09:14:11+0000" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Professional NonClinician (version 2.0.0)

identifier: Unique Claim ID: AW123412341234123412341234123413

status: active

type: Professional (Claim Type Codes#professional)

use: claim

patient: Patient/Patient2 " TEST"

billablePeriod: 2019-01-01 --> 2019-10-31

created: 2019-07-02 12:00:00+0000

insurer: Organization/Payer1: XXX Health Plan "Organization Payer 1"

provider: Organization/ProviderOrganization1: XXX Health Plan "Orange Medical Group"

outcome: partial

supportingInfo

sequence: 3

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

timing: 2011-05-30

supportingInfo

sequence: 4

category: Service Facility (C4BB Supporting Info Type Code System#servicefacility)

value: Organization/ProviderOrganization1 "Orange Medical Group"

supportingInfo

sequence: 5

category: Medical Record Number (C4BB Supporting Info Type Code System#medicalrecordnumber)

value: 1234-234-1243-12345678901m

supportingInfo

sequence: 6

category: Patient Account Number (C4BB Supporting Info Type Code System#patientaccountnumber)

value: 1234-234-1243-12345678901a

Diagnoses

-SequenceDiagnosis[x]Type
*1Concussion w LOC of 30 minutes or less, init (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.0X1A)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-FocalCoverage
*trueCoverage/Coverage3

item

sequence: 1

productOrService: Physical Therapy (Current Procedural Terminology (CPT®)#97110)

serviced: 2019-07-02

location: Office (CMS Place of Service Codes (POS)#11)

adjudication

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

reason: Other (C4BB Payer Adjudication Status Code System#other)

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)

Amounts

-ValueCurrency
*1000USD

Adjudications

-CategoryReason
*Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus)In Network (C4BB Payer Adjudication Status Code System#innetwork)
*Rendering Network Status (C4BB Adjudication Discriminator Code System#renderingnetworkstatus)In Network (C4BB Payer Adjudication Status Code System#innetwork)

total

category: Payment Amount (C4BB Adjudication Code System#paidtoprovider)

Amounts

-ValueCurrency
*620USD

total

category: Submitted Amount (Adjudication Value Codes#submitted)

Amounts

-ValueCurrency
*2650USD

total

category: Patient Pay Amount (C4BB Adjudication Code System#paidbypatient)

Amounts

-ValueCurrency
*0USD

Notes:

Instance: EOBProfessional1
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Example 1"
Description: "EOB Professional - Example 1"
Usage: #example
* meta.lastUpdated = "2019-12-12T09:14:11+00:00"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.0.0"
* language = #en-US
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc
* identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier"
* identifier.value = "AW123412341234123412341234123413"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
  * text = "Professional"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2019-01-01"
* billablePeriod.end = "2019-10-31"
* created = "2019-07-02T00:00:00+00:00"
* insurer = Reference(Payer1) "XXX Health Plan"
* provider = Reference(ProviderOrganization1) "XXX Health Plan"
* outcome = #partial
* supportingInfo[0].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2011-05-30"
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#servicefacility
* supportingInfo[=].valueReference = Reference(ProviderOrganization1)
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#medicalrecordnumber
* supportingInfo[=].valueString = "1234-234-1243-12345678901m"
* supportingInfo[+].sequence = 6
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientaccountnumber
* supportingInfo[=].valueString = "1234-234-1243-12345678901a"
* diagnosis.sequence = 1
* diagnosis.diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A
* diagnosis.type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item.sequence = 1
* item.productOrService = http://www.ama-assn.org/go/cpt#97110 "Physical Therapy"
* item.servicedDate = "2019-07-02"
* item.locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* item.adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item.adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#other
* item.adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* item.adjudication[=].amount.value = 1000
* item.adjudication[=].amount.currency = #USD
* adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#renderingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* total[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* total[=].category.text = "Payment Amount"
* total[=].amount.value = 620
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
  * text = "Submitted Amount"
* total[=].amount.value = 2650
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidbypatient
  * text = "Patient Pay Amount"
* total[=].amount.value = 0
* total[=].amount.currency = #USD