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 Professional - Transportation 1

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBProfessionalTransportation1" Updated "2022-09-10 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: ProfessionalTransportationEOBExample1

status: active

type: Professional (Claim Type Codes#professional)

subType: Patient was transported for the benefit of a preferred physician (X12 Ambulance Transport Reason Codes Code System#B)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2022-09-10 --> (ongoing)

created: 2022-09-10 02:46:05-0400

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

provider: Organization/ProviderTransportationOrganization1 "ABC Ambulance Services"

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider")Organization/ProviderTransportationOrganization1 "ABC Ambulance Services"

outcome: complete

CareTeams

-SequenceProviderRoleQualification
*1Organization/ProviderTransportationOrganization1 "ABC Ambulance Services"The rendering care provider. (C4BB Claim Care Team Role Code System#rendering "Rendering provider")Transportation Services; Non-emergency Medical Transport (VAN) (provider-taxonomy#343900000X)

supportingInfo

sequence: 1

category: Date the claim was received by the payer. (C4BB Supporting Info Type Code System#clmrecvddate "Claim Received Date")

timing: 2022-09-11

supportingInfo

sequence: 2

category: Patient Weight (C4BB Supporting Info Type Code System#patientweight)

value: 160 [lb_av]

supportingInfo

sequence: 3

category: Ambulance Transport Reason (C4BB Supporting Info Type Code System#ambulancetransportreason)

reason: Patient was transported for the benefit of a preferred physician (Details: https://x12.org/codesystem.x12.org/ambulance-transport-reason-codes code B = 'B', stated as 'Patient was transported for the benefit of a preferred physician')

supportingInfo

sequence: 4

category: Transportation Distance (C4BB Supporting Info Type Code System#transportationdistance)

value: 21 [mi_i]

supportingInfo

sequence: 5

category: Transportation Distance (C4BB Supporting Info Type Code System#transportationdistance)

value: 22 [mi_i]

supportingInfo

sequence: 6

category: Round Trip Purpose (C4BB Supporting Info Type Code System#roudtrippurpose)

value: Trip to facility and then back home

supportingInfo

sequence: 7

category: Stretcher Purpose (C4BB Supporting Info Type Code System#stretcherpurpose)

value: Patient could not walk

supportingInfo

sequence: 8

category: Pick-up Location (C4BB Supporting Info Type Code System#pickuplocation)

value: Patient home; Pittsburgh; PA,15222

supportingInfo

sequence: 9

category: Drop-off Location (C4BB Supporting Info Type Code System#dropofflocation)

value: Orange Medical Group; Pittsburgh; PA,15222

supportingInfo

sequence: 10

category: Pick-up Location (C4BB Supporting Info Type Code System#pickuplocation)

value: Orange Medical Group; Pittsburgh; PA,15222

supportingInfo

sequence: 11

category: Drop-off Location (C4BB Supporting Info Type Code System#dropofflocation)

value: Patient home; Pittsburgh; PA,15222

Diagnoses

-SequenceDiagnosis[x]Type
*1Athscl native arteries of left leg w ulceration of unsp site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I70.249)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")

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

informationSequence: 2, 3, 4, 6, 7, 10, 11

productOrService: Ambulance service, basic life support, non-emergency transport (BLS) (Current Procedural Terminology (CPT®)#A0428)

serviced: 2022-09-10

location: Ambulance - Land (CMS Place of Service Codes (POS)#41)

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
*40.35USD

adjudication

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

Amounts

-ValueCurrency
*40.35USD

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
*40.35USD

item

sequence: 2

informationSequence: 2, 3, 5, 6, 7, 8, 9

productOrService: Ambulance service, basic life support, non-emergency transport (BLS) (Current Procedural Terminology (CPT®)#A0428)

serviced: 2022-09-10

location: Ambulance - Land (CMS Place of Service Codes (POS)#41)

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
*42.62USD

adjudication

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

Amounts

-ValueCurrency
*42.62USD

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
*42.62USD

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
*82.97USD

total

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

Amounts

-ValueCurrency
*82.97USD

total

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

Amounts

-ValueCurrency
*82.97USD

total

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

Amounts

-ValueCurrency
*0USD

Notes:

Instance: EOBProfessionalTransportation1
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Transportation 1"
Description: "EOB Professional - Transportation 1"
Usage: #example
* meta.lastUpdated = "2022-09-10T14:46:05-04:00"
* 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.example.com/fhir/EOBIdentifier"
* identifier.value = "ProfessionalTransportationEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
  * text = "Professional"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2022-09-10"
* created = "2022-09-10T14:46:05-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderTransportationOrganization1)
* 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(ProviderTransportationOrganization1)
* outcome = #complete
* careTeam.sequence = 1
* careTeam.provider = Reference(ProviderTransportationOrganization1)
* careTeam.role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#rendering "Rendering provider"
  * text = "The rendering care provider."
* careTeam.qualification = http://nucc.org/provider-taxonomy#343900000X "Transportation Services; Non-emergency Medical Transport (VAN)"
* supportingInfo[0].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 = "2022-09-11"
* supportingInfo[+].sequence = 2
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientweight
* supportingInfo[=].valueQuantity.value = 160
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[lb_av]"
* supportingInfo[+].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#ambulancetransportreason
* supportingInfo[=].reason = https://x12.org/codesystem.x12.org/5010/1317#B "Patient was transported for the benefit of a preferred physician"
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#transportationdistance
* supportingInfo[=].valueQuantity.value = 21
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[mi_i]"
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#transportationdistance
* supportingInfo[=].valueQuantity.value = 22
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[mi_i]"
* supportingInfo[+].sequence = 6
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#roudtrippurpose
* supportingInfo[=].valueString = "Trip to facility and then back home"
* supportingInfo[+].sequence = 7
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#stretcherpurpose
* supportingInfo[=].valueString = "Patient could not walk"
* supportingInfo[+].sequence = 8
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#pickuplocation
* supportingInfo[=].valueString = "Patient home; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 9
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dropofflocation
* supportingInfo[=].valueString = "Orange Medical Group; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 10
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#pickuplocation
* supportingInfo[=].valueString = "Orange Medical Group; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 11
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dropofflocation
* supportingInfo[=].valueString = "Patient home; Pittsburgh; PA,15222"
* diagnosis.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."
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].informationSequence[0] = 2
* item[=].informationSequence[+] = 3
* item[=].informationSequence[+] = 4
* item[=].informationSequence[+] = 6
* item[=].informationSequence[+] = 7
* item[=].informationSequence[+] = 10
* item[=].informationSequence[+] = 11
* item[=].productOrService = http://www.ama-assn.org/go/cpt#A0428 "Ambulance service, basic life support, non-emergency transport (BLS)"
* item[=].servicedDate = "2022-09-10"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#41
  * text = "Ambulance - Land"
* 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 = 40.35
* 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 = 40.35
* 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 = 40.35
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 2
* item[=].informationSequence[0] = 2
* item[=].informationSequence[+] = 3
* item[=].informationSequence[+] = 5
* item[=].informationSequence[+] = 6
* item[=].informationSequence[+] = 7
* item[=].informationSequence[+] = 8
* item[=].informationSequence[+] = 9
* item[=].productOrService = http://www.ama-assn.org/go/cpt#A0428 "Ambulance service, basic life support, non-emergency transport (BLS)"
* item[=].servicedDate = "2022-09-10"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#41
  * text = "Ambulance - Land"
* 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 = 42.62
* 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 = 42.62
* 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 = 42.62
* 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 = 82.97
* 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 = 82.97
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
  * text = "Amount payable under the coverage"
* total[=].amount.value = 82.97
* 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