{ "resourceType" : "ExplanationOfBenefit", "id" : "BB-EOBInpatient2-nonfinancial", "meta" : { "lastUpdated" : "2020-04-28T15:39:36-04:00", "profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis|2.2.0"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: ExplanationOfBenefit BB-EOBInpatient2-nonfinancial

Last updated: 2020-04-28 15:39:36-0400; Language: en

Profile: C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: null2.2.0)

identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/InpatientEOBExample1

status: Active

type: Institutional

subType: Inpatient

use: Claim

patient: Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)

billablePeriod: 2017-05-23 --> 2017-05-23

created: 2017-06-01 00:00:00-0400

insurer: UPMC Health Plan

provider: Organization Green Medical Group

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit).Organization Blue Medical Group

outcome: Processing Complete

careTeam

sequence: 1

provider: Practitioner Jack Brown

role: The attending physician

careTeam

sequence: 2

provider: Practitioner Jack Brown

role: The referring physician

supportingInfo

sequence: 2

category: Admission Period

timing: 2017-05-23 --> (ongoing)

supportingInfo

sequence: 1

category: Claim Received Date

timing: 2017-06-01

diagnosis

sequence: 1

diagnosis: Non-ST elevation (NSTEMI) myocardial infarction

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

diagnosis

sequence: 2

diagnosis: Athscl heart disease of native cor art w oth ang pctrs

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 3

diagnosis: Hyperlipidemia, unspecified

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 4

diagnosis: Unspecified osteoarthritis, unspecified site

type: Required when other conditions coexist or develop subsequently during the treatment

procedure

sequence: 1

type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis

date: 2017-05-23

procedure: Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach

procedure

sequence: 2

type: Other procedures performed during the inpatient institutional admission

date: 2017-05-23

procedure: Fluoroscopy of Multiple Coronary Arteries using Other Contrast

procedure

sequence: 3

type: Other procedures performed during the inpatient institutional admission

date: 2017-05-23

procedure: Fluoroscopy of Left Heart using Other Contrast

Insurances

-FocalCoverage
*trueCoverage: identifier = An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.:\u00a088800933501; status = active; subscriberId = 888009335; dependent = 01; relationship = Self; period = 2017-01-01 --> 2017-06-30; network = GI8-HMO DEDUCTIBLE

item

sequence: 1

revenue: 0301

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 2

revenue: 0260

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 3

revenue: 0305

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 4

revenue: 0324

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 5

revenue: 0259

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 6

revenue: 0250

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 7

revenue: 0710

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 8

revenue: 0210

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 9

revenue: 0272

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 10

revenue: 0370

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 11

revenue: 0730

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 12

revenue: 0450

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

item

sequence: 13

revenue: 0481

productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

Adjudications

-CategoryReason
*Benefit Payment StatusOut Of Network
*Billing Network StatusIndicates the provider was in network for the service
" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType", "code" : "uc", "display" : "Unique Claim ID" }], "text" : "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" }, "system" : "https://www.example.com/fhir/EOBIdentifier", "value" : "InpatientEOBExample1" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "version" : "1.0.1", "code" : "institutional" }], "text" : "Institutional" }, "subType" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType", "code" : "inpatient" }], "text" : "Inpatient" }, "use" : "claim", "patient" : { "reference" : "Patient/Patient1" }, "billablePeriod" : { "start" : "2017-05-23", "end" : "2017-05-23" }, "created" : "2017-06-01T00:00:00-04:00", "insurer" : { "reference" : "Organization/Payer2", "display" : "UPMC Health Plan" }, "provider" : { "reference" : "Organization/ProviderOrganization3" }, "payee" : { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/payeetype", "version" : "1.0.1", "code" : "provider", "display" : "Provider" }], "text" : "Any benefit payable will be paid to the provider (Assignment of Benefit)." }, "party" : { "reference" : "Organization/ProviderOrganization4" } }, "outcome" : "complete", "careTeam" : [{ "sequence" : 1, "provider" : { "reference" : "Practitioner/Practitioner2" }, "role" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "code" : "attending", "display" : "Attending" }], "text" : "The attending physician" } }, { "sequence" : 2, "provider" : { "reference" : "Practitioner/Practitioner2" }, "role" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "code" : "referring", "display" : "Referring" }], "text" : "The referring physician" } }], "supportingInfo" : [{ "sequence" : 2, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "admissionperiod" }] }, "timingPeriod" : { "start" : "2017-05-23" } }, { "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "clmrecvddate" }] }, "timingDate" : "2017-06-01" }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "I21.4" }] }, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "version" : "1.0.1", "code" : "principal", "display" : "Principal Diagnosis" }], "text" : "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." }] }, { "sequence" : 2, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "I25.118" }] }, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType", "code" : "other", "display" : "Other" }], "text" : "Required when other conditions coexist or develop subsequently during the treatment" }] }, { "sequence" : 3, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "E78.5" }] }, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType", "code" : "other", "display" : "Other" }], "text" : "Required when other conditions coexist or develop subsequently during the treatment" }] }, { "sequence" : 4, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "M19.90" }] }, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType", "code" : "other", "display" : "Other" }], "text" : "Required when other conditions coexist or develop subsequently during the treatment" }] }], "procedure" : [{ "sequence" : 1, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType", "code" : "principal", "display" : "Principal" }], "text" : "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis" }], "date" : "2017-05-23", "procedureCodeableConcept" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/ICD10", "code" : "4A023N7" }] } }, { "sequence" : 2, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType", "code" : "other", "display" : "Other" }], "text" : "Other procedures performed during the inpatient institutional admission" }], "date" : "2017-05-23", "procedureCodeableConcept" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/ICD10", "code" : "B211YZZ" }] } }, { "sequence" : 3, "type" : [{ "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType", "code" : "other", "display" : "Other" }], "text" : "Other procedures performed during the inpatient institutional admission" }], "date" : "2017-05-23", "procedureCodeableConcept" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/ICD10", "code" : "B215YZZ" }] } }], "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/Coverage2" } }], "item" : [{ "sequence" : 1, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0301" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 2, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0260" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 3, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0305" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 4, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0324" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 5, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0259" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 6, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0250" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 7, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0710" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 8, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0210" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 9, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0272" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 10, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0370" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 11, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0730" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 12, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0450" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }, { "sequence" : 13, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0481" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedPeriod" : { "start" : "2017-05-23" }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }], "text" : "HOSPITAL - INPATIENT HOSPITAL" } }], "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "benefitpaymentstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "outofnetwork" }] } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "billingnetworkstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "innetwork", "display" : "In Network" }], "text" : "Indicates the provider was in network for the service" } }] }