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 2

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBProfessional2" Updated "2020-10-20 02:46:05-0400"

Information Source: Organization/PayerOrganizationExample1!

Profile: C4BB ExplanationOfBenefit Professional NonClinician (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: ProfessionalEOBExample1

status: active

type: Professional (Claim Type Codes#professional)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2020-08-04 --> 2020-08-04

created: 2020-08-24 12:00:00-0400

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

provider: Organization/ProviderOrganization1 "Orange Medical Group"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider")Organization/ProviderOrganization1 "Orange Medical Group"

outcome: complete

careTeam

sequence: 1

provider: Organization/ProviderOrganization1 "Orange Medical Group"

role: The primary care provider. (Claim Care Team Role Codes#primary "Primary provider")

careTeam

sequence: 2

provider: Practitioner/Practitioner1 " SMITH"

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

SupportingInfos

-SequenceCategoryTiming[x]
*1Date the claim was received by the payer. (C4BB Supporting Info Type Code System#clmrecvddate "Claim Received Date")2020-08-24

diagnosis

sequence: 1

diagnosis: Athscl native arteries of left leg w ulceration of unsp site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I70.249)

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: Non-prs chronic ulc unsp prt of l low leg w unsp severity (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#L97.929)

type: Required when necessary to report additional diagnoses on professional and non-clinician claims (C4BB Claim Diagnosis Type Code System#secondary "secondary")

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*68.8USD

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
*34.8USD

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
*34.8USD

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

productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*-68.8USD

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
*-34.8USD

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
*-34.8USD

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: 3

productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*68.8USD

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
*34.8USD

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
*34.8USD

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: 4

productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*751.2USD

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
*224.11USD

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
*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
*224.11USD

item

sequence: 5

productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*751.2USD

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
*224.11USD

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
*224.11USD

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: 6

productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)

serviced: 2020-08-04

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

adjudication

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

reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)

adjudication

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

Amounts

-ValueCurrency
*-751.2USD

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
*-224.11USD

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
*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
*-224.11USD

Adjudications

-CategoryReason
*Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. (C4BB Adjudication Discriminator Code System#billingnetworkstatus "Billing Network Status")Indicates the provider was in network for the service (C4BB Payer Adjudication Status Code System#innetwork "In Network")

total

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

Amounts

-ValueCurrency
*820USD

total

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

Amounts

-ValueCurrency
*258.91USD

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
*258.91USD

total

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

Amounts

-ValueCurrency
*0USD

Notes:

Instance: EOBProfessional2
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Example 2"
Description: "EOB Professional - Example 2"
Usage: #example
* meta.lastUpdated = "2020-10-20T14:46:05-04:00"
* meta.source = "Organization/PayerOrganizationExample1"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|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 = "ProfessionalEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
  * text = "Professional"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2020-08-04"
* billablePeriod.end = "2020-08-04"
* created = "2020-08-24T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization1)
* 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(ProviderOrganization1)
* outcome = #complete
* careTeam[0].sequence = 1
* careTeam[=].provider = Reference(ProviderOrganization1)
* careTeam[=].role = http://terminology.hl7.org/CodeSystem/claimcareteamrole#primary "Primary provider"
  * text = "The primary care provider."
* careTeam[+].sequence = 2
* careTeam[=].provider = Reference(Practitioner1)
* 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 "Claim Received Date"
  * text = "Date the claim was received by the payer."
* supportingInfo.timingDate = "2020-08-24"
* diagnosis[0].sequence = 1
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I70.249
* 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#L97.929
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#secondary "secondary"
  * text = "Required when necessary to report additional diagnoses on professional and non-clinician claims"
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 68.8
* 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 = 34.8
* 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 = 34.8
* 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[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = -68.8
* 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 = -34.8
* 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 = -34.8
* 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 = 3
* item[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 68.8
* 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 = 34.8
* 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 = 34.8
* 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 = 4
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 751.2
* 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 = 224.11
* 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 = 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 = 224.11
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 5
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 751.2
* 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 = 224.11
* 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 = 224.11
* 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 = 6
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
  * text = "HOSPITAL - INPATIENT HOSPITAL"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
  * text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = -751.2
* 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 = -224.11
* 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 = 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 = -224.11
* item[=].adjudication[=].amount.currency = #USD
* adjudication.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus "Billing Network Status"
  * text = "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
* adjudication.reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork "In Network"
  * text = "Indicates the provider was in network for the service"
* 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 = 820
* 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 = 258.91
* 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 = 258.91
* 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