CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.0.0 - STU1

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.0.0). 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

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

use: claim

patient: Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; unknown

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

created: Aug 24, 2020, 4:00:00 AM

insurer: UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; Payer; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762

provider: Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit).Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group

outcome: complete

careTeam

sequence: 1

provider: Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group

role: The primary care provider.

careTeam

sequence: 2

provider: Generated Summary: National Provider Identifier: 6667778880; active; John Smith

role: The referring physician

supportingInfo

sequence: 1

category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.

code: Indicates the provider was contracted for the service

supportingInfo

sequence: 2

category: Date the claim was received by the payer.

timing: 2020-08-24

diagnosis

sequence: 1

diagnosis: I70.249

type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.

diagnosis

sequence: 2

diagnosis: L97.929

type: Required when necessary to report additional diagnoses on professional and non-clinician claims

Insurances

-FocalCoverage
*trueGenerated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status: active; subscriberId: 888009335; dependent: 01; Self; period: 2020-01-01 --> (ongoing); network: GR5-HMO DEDUCTIBLE

item

sequence: 1

productOrService: 75710

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

item

sequence: 2

productOrService: 75710

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

item

sequence: 3

productOrService: 75710

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

item

sequence: 4

productOrService: 37228

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

item

sequence: 5

productOrService: 37228

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

item

sequence: 6

productOrService: 37228

serviced: 2020-08-04

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

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.

Amounts

-
*

adjudication

category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

total

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

total

category: Amount of the change which is considered for adjudication.

Amounts

-
*

total

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

total

category: Patient Co-Payment

Amounts

-
*

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.

Amounts

-
*

total

category: Amount payable under the coverage

Amounts

-
*

total

category: The amount of the member's liability.

Amounts

-
*

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "ProfessionalEOBExample1"
meta.lastUpdated "2020-10-20T14:46:05-04:00"
meta.source "Organization/PayerOrganizationExample1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician"
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].display "Unique Claim ID"
identifier[0].type.text "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
identifier[0].system "https://www.upmchealthplan.com/fhir/EOBIdentifier"
identifier[0].value ProfessionalEOBExample1
status "active"
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.coding[0].code #professional
type.text "Professional"
use "claim"
patient.reference "Patient/ExamplePatient1"
billablePeriod.start "2020-08-04"
billablePeriod.end "2020-08-04"
created "2020-08-24T00:00:00-04:00"
insurer.reference "Organization/PayerOrganizationExample1"
insurer.display "UPMC Health Plan"
provider.reference "Organization/ProviderOrganization1"
payee.type.coding[0].system "http://terminology.hl7.org/CodeSystem/payeetype"
payee.type.coding[0].code #provider
payee.type.coding[0].display "Provider"
payee.type.text "Any benefit payable will be paid to the provider (Assignment of Benefit)."
payee.party.reference "Organization/ProviderOrganization1"
outcome "complete"
careTeam[0].sequence 1
careTeam[0].provider.reference "Organization/ProviderOrganization1"
careTeam[0].role.coding[0].system "http://terminology.hl7.org/CodeSystem/claimcareteamrole"
careTeam[0].role.coding[0].code #primary
careTeam[0].role.coding[0].display "Primary provider"
careTeam[0].role.text "The primary care provider."
careTeam[1].sequence 2
careTeam[1].provider.reference "Practitioner/Practitioner1"
careTeam[1].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[1].role.coding[0].code #referring
careTeam[1].role.coding[0].display "Referring"
careTeam[1].role.text "The referring physician"
supportingInfo[0].sequence 1
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].category.coding[0].display "Billing Network Contracting Status"
supportingInfo[0].category.text "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[0].code.coding[0].display "Contracted"
supportingInfo[0].code.text "Indicates the provider was contracted for the service"
supportingInfo[1].sequence 2
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].category.coding[0].code #clmrecvddate
supportingInfo[1].category.coding[0].display "Claim Received Date"
supportingInfo[1].category.text "Date the claim was received by the payer."
supportingInfo[1].timingDate "2020-08-24"
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #I70.249
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].type[0].coding[0].code #principal
diagnosis[0].type[0].coding[0].display "Principal Diagnosis"
diagnosis[0].type[0].text "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
diagnosis[1].sequence 2
diagnosis[1].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[1].diagnosisCodeableConcept.coding[0].code #L97.929
diagnosis[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[1].type[0].coding[0].code #secondary
diagnosis[1].type[0].coding[0].display "secondary"
diagnosis[1].type[0].text "Required when necessary to report additional diagnoses on professional and non-clinician claims"
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageEx1"
item[0].sequence 1
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].code #75710
item[0].servicedDate "2020-08-04"
item[0].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[0].locationCodeableConcept.coding[0].code #21
item[0].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].display "Submitted Amount"
item[0].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[0].adjudication[0].amount.value 68.8
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[1].category.coding[0].code #copay
item[0].adjudication[1].category.coding[0].display "CoPay"
item[0].adjudication[1].category.text "Patient Co-Payment"
item[0].adjudication[1].amount.value 0.0
item[0].adjudication[1].amount.currency #USD
item[0].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[2].category.coding[0].code #eligible
item[0].adjudication[2].category.coding[0].display "Eligible Amount"
item[0].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[0].adjudication[2].amount.value 34.8
item[0].adjudication[2].amount.currency #USD
item[0].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[3].category.coding[0].code #deductible
item[0].adjudication[3].category.coding[0].display "Deductible"
item[0].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[0].adjudication[3].amount.value 0.0
item[0].adjudication[3].amount.currency #USD
item[0].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[4].category.coding[0].code #benefit
item[0].adjudication[4].category.coding[0].display "Benefit Amount"
item[0].adjudication[4].category.text "Amount payable under the coverage"
item[0].adjudication[4].amount.value 34.8
item[0].adjudication[4].amount.currency #USD
item[0].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[5].category.coding[0].code #noncovered
item[0].adjudication[5].category.coding[0].display "Noncovered"
item[0].adjudication[5].category.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[0].adjudication[5].amount.value 0.0
item[0].adjudication[5].amount.currency #USD
item[0].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[0].adjudication[6].category.coding[0].code #innetwork
item[0].adjudication[6].category.coding[0].display "In Network"
item[0].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
item[1].sequence 2
item[1].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[1].productOrService.coding[0].code #75710
item[1].servicedDate "2020-08-04"
item[1].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[1].locationCodeableConcept.coding[0].code #21
item[1].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[1].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[0].category.coding[0].code #submitted
item[1].adjudication[0].category.coding[0].display "Submitted Amount"
item[1].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[1].adjudication[0].amount.value -68.8
item[1].adjudication[0].amount.currency #USD
item[1].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[1].category.coding[0].code #copay
item[1].adjudication[1].category.coding[0].display "CoPay"
item[1].adjudication[1].category.text "Patient Co-Payment"
item[1].adjudication[1].amount.value 0.0
item[1].adjudication[1].amount.currency #USD
item[1].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[2].category.coding[0].code #eligible
item[1].adjudication[2].category.coding[0].display "Eligible Amount"
item[1].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[1].adjudication[2].amount.value -34.8
item[1].adjudication[2].amount.currency #USD
item[1].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[3].category.coding[0].code #deductible
item[1].adjudication[3].category.coding[0].display "Deductible"
item[1].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[1].adjudication[3].amount.value 0.0
item[1].adjudication[3].amount.currency #USD
item[1].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[4].category.coding[0].code #benefit
item[1].adjudication[4].category.coding[0].display "Benefit Amount"
item[1].adjudication[4].category.text "Amount payable under the coverage"
item[1].adjudication[4].amount.value -34.8
item[1].adjudication[4].amount.currency #USD
item[1].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[1].adjudication[5].category.coding[0].code #noncovered
item[1].adjudication[5].category.coding[0].display "Noncovered"
item[1].adjudication[5].category.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[1].adjudication[5].amount.value 0.0
item[1].adjudication[5].amount.currency #USD
item[1].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[1].adjudication[6].category.coding[0].code #innetwork
item[1].adjudication[6].category.coding[0].display "In Network"
item[1].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
item[2].sequence 3
item[2].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[2].productOrService.coding[0].code #75710
item[2].servicedDate "2020-08-04"
item[2].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[2].locationCodeableConcept.coding[0].code #21
item[2].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[2].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[0].category.coding[0].code #submitted
item[2].adjudication[0].category.coding[0].display "Submitted Amount"
item[2].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[2].adjudication[0].amount.value 68.8
item[2].adjudication[0].amount.currency #USD
item[2].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[1].category.coding[0].code #copay
item[2].adjudication[1].category.coding[0].display "CoPay"
item[2].adjudication[1].category.text "Patient Co-Payment"
item[2].adjudication[1].amount.value 0.0
item[2].adjudication[1].amount.currency #USD
item[2].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[2].category.coding[0].code #eligible
item[2].adjudication[2].category.coding[0].display "Eligible Amount"
item[2].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[2].adjudication[2].amount.value 34.8
item[2].adjudication[2].amount.currency #USD
item[2].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[3].category.coding[0].code #deductible
item[2].adjudication[3].category.coding[0].display "Deductible"
item[2].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[2].adjudication[3].amount.value 0.0
item[2].adjudication[3].amount.currency #USD
item[2].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[4].category.coding[0].code #benefit
item[2].adjudication[4].category.coding[0].display "Benefit Amount"
item[2].adjudication[4].category.text "Amount payable under the coverage"
item[2].adjudication[4].amount.value 34.8
item[2].adjudication[4].amount.currency #USD
item[2].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[2].adjudication[5].category.coding[0].code #noncovered
item[2].adjudication[5].category.coding[0].display "Noncovered"
item[2].adjudication[5].category.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[2].adjudication[5].amount.value 0.0
item[2].adjudication[5].amount.currency #USD
item[2].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[2].adjudication[6].category.coding[0].code #innetwork
item[2].adjudication[6].category.coding[0].display "In Network"
item[2].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
item[3].sequence 4
item[3].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[3].productOrService.coding[0].code #37228
item[3].servicedDate "2020-08-04"
item[3].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[3].locationCodeableConcept.coding[0].code #21
item[3].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[3].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[0].category.coding[0].code #submitted
item[3].adjudication[0].category.coding[0].display "Submitted Amount"
item[3].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[3].adjudication[0].amount.value 751.2
item[3].adjudication[0].amount.currency #USD
item[3].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[1].category.coding[0].code #copay
item[3].adjudication[1].category.coding[0].display "CoPay"
item[3].adjudication[1].category.text "Patient Co-Payment"
item[3].adjudication[1].amount.value 0.0
item[3].adjudication[1].amount.currency #USD
item[3].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[2].category.coding[0].code #eligible
item[3].adjudication[2].category.coding[0].display "Eligible Amount"
item[3].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[3].adjudication[2].amount.value 224.11
item[3].adjudication[2].amount.currency #USD
item[3].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[3].category.coding[0].code #deductible
item[3].adjudication[3].category.coding[0].display "Deductible"
item[3].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[3].adjudication[3].amount.value 0.0
item[3].adjudication[3].amount.currency #USD
item[3].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[4].category.coding[0].code #benefit
item[3].adjudication[4].category.coding[0].display "Benefit Amount"
item[3].adjudication[4].category.text "Amount payable under the coverage"
item[3].adjudication[4].amount.value 0.0
item[3].adjudication[4].amount.currency #USD
item[3].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[3].adjudication[5].category.coding[0].code #noncovered
item[3].adjudication[5].category.coding[0].display "Noncovered"
item[3].adjudication[5].category.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[3].adjudication[5].amount.value 224.11
item[3].adjudication[5].amount.currency #USD
item[3].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[3].adjudication[6].category.coding[0].code #innetwork
item[3].adjudication[6].category.coding[0].display "In Network"
item[3].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
item[4].sequence 5
item[4].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[4].productOrService.coding[0].code #37228
item[4].servicedDate "2020-08-04"
item[4].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[4].locationCodeableConcept.coding[0].code #21
item[4].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[4].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[0].category.coding[0].code #submitted
item[4].adjudication[0].category.coding[0].display "Submitted Amount"
item[4].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[4].adjudication[0].amount.value 751.2
item[4].adjudication[0].amount.currency #USD
item[4].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[1].category.coding[0].code #copay
item[4].adjudication[1].category.coding[0].display "CoPay"
item[4].adjudication[1].category.text "Patient Co-Payment"
item[4].adjudication[1].amount.value 0.0
item[4].adjudication[1].amount.currency #USD
item[4].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[2].category.coding[0].code #eligible
item[4].adjudication[2].category.coding[0].display "Eligible Amount"
item[4].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[4].adjudication[2].amount.value 224.11
item[4].adjudication[2].amount.currency #USD
item[4].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[3].category.coding[0].code #deductible
item[4].adjudication[3].category.coding[0].display "Deductible"
item[4].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[4].adjudication[3].amount.value 0.0
item[4].adjudication[3].amount.currency #USD
item[4].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[4].category.coding[0].code #benefit
item[4].adjudication[4].category.coding[0].display "Benefit Amount"
item[4].adjudication[4].category.text "Amount payable under the coverage"
item[4].adjudication[4].amount.value 224.11
item[4].adjudication[4].amount.currency #USD
item[4].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[4].adjudication[5].category.coding[0].code #noncovered
item[4].adjudication[5].category.coding[0].display "Noncovered"
item[4].adjudication[5].category.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[4].adjudication[5].amount.value 0.0
item[4].adjudication[5].amount.currency #USD
item[4].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[4].adjudication[6].category.coding[0].code #innetwork
item[4].adjudication[6].category.coding[0].display "In Network"
item[4].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
item[5].sequence 6
item[5].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[5].productOrService.coding[0].code #37228
item[5].servicedDate "2020-08-04"
item[5].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[5].locationCodeableConcept.coding[0].code #21
item[5].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[5].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[0].category.coding[0].code #submitted
item[5].adjudication[0].category.coding[0].display "Submitted Amount"
item[5].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[5].adjudication[0].amount.value -751.2
item[5].adjudication[0].amount.currency #USD
item[5].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[1].category.coding[0].code #copay
item[5].adjudication[1].category.coding[0].display "CoPay"
item[5].adjudication[1].category.text "Patient Co-Payment"
item[5].adjudication[1].amount.value 0.0
item[5].adjudication[1].amount.currency #USD
item[5].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[2].category.coding[0].code #eligible
item[5].adjudication[2].category.coding[0].display "Eligible Amount"
item[5].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[5].adjudication[2].amount.value -224.11
item[5].adjudication[2].amount.currency #USD
item[5].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[3].category.coding[0].code #deductible
item[5].adjudication[3].category.coding[0].display "Deductible"
item[5].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[5].adjudication[3].amount.value 0.0
item[5].adjudication[3].amount.currency #USD
item[5].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[4].category.coding[0].code #benefit
item[5].adjudication[4].category.coding[0].display "Benefit Amount"
item[5].adjudication[4].category.text "Amount payable under the coverage"
item[5].adjudication[4].amount.value 0.0
item[5].adjudication[4].amount.currency #USD
item[5].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[5].adjudication[5].category.coding[0].code #noncovered
item[5].adjudication[5].category.coding[0].display "Noncovered"
item[5].adjudication[5].category.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[5].adjudication[5].amount.value -224.11
item[5].adjudication[5].amount.currency #USD
item[5].adjudication[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[5].adjudication[6].category.coding[0].code #innetwork
item[5].adjudication[6].category.coding[0].display "In Network"
item[5].adjudication[6].category.text "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"
total[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[0].category.coding[0].code #submitted
total[0].category.coding[0].display "Submitted Amount"
total[0].category.text "The total submitted amount for the claim or group or line item."
total[0].amount.value 820.0
total[0].amount.currency #USD
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.coding[0].code #eligible
total[1].category.coding[0].display "Eligible Amount"
total[1].category.text "Amount of the change which is considered for adjudication."
total[1].amount.value 258.91
total[1].amount.currency #USD
total[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[2].category.coding[0].code #deductible
total[2].category.coding[0].display "Deductible"
total[2].category.text "Amount deducted from the eligible amount prior to adjudication."
total[2].amount.value 0.0
total[2].amount.currency #USD
total[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[3].category.coding[0].code #copay
total[3].category.coding[0].display "CoPay"
total[3].category.text "Patient Co-Payment"
total[3].amount.value 0.0
total[3].amount.currency #USD
total[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[4].category.coding[0].code #noncovered
total[4].category.coding[0].display "Noncovered"
total[4].category.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[4].amount.value 0.0
total[4].amount.currency #USD
total[5].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[5].category.coding[0].code #benefit
total[5].category.coding[0].display "Benefit Amount"
total[5].category.text "Amount payable under the coverage"
total[5].amount.value 258.91
total[5].amount.currency #USD
total[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[6].category.coding[0].code #memberliability
total[6].category.coding[0].display "Member liability"
total[6].category.text "The amount of the member's liability."
total[6].amount.value 0.0
total[6].amount.currency #USD