{ "resourceType" : "ExplanationOfBenefit", "id" : "EOBOutpatient2", "meta" : { "lastUpdated" : "2020-10-13T11:10:24-04:00", "profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.2.0"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: ExplanationOfBenefit EOBOutpatient2

Last updated: 2020-10-13 11:10:24-0400; Language: en

Profile: C4BB ExplanationOfBenefit Outpatient Institutionalversion: null2.2.0)

identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/OutpatientEOBExample1

status: Active

type: Institutional

subType: Outpatient

use: Claim

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

billablePeriod: 2020-09-29 --> 2020-09-29

created: 2020-10-10 00:00:00-0400

insurer: UPMC Health Plan

provider: Organization Black Medical Group

Payees

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

outcome: Processing Complete

careTeam

sequence: 1

provider: Practitioner John Smith

role: The attending physician

careTeam

sequence: 2

provider: Practitioner Jane Williams

role: The referring physician

SupportingInfos

-SequenceCategoryTiming[x]
*1Claim Received Date2020-10-10

diagnosis

sequence: 1

diagnosis: Orthostatic hypotension

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

diagnosis

sequence: 2

diagnosis: Orthostatic hypotension

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

diagnosis

sequence: 3

diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity

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

diagnosis

sequence: 4

diagnosis: Peripheral vascular disease, unspecified

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

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 = 2020-01-01 --> (ongoing); network = GR5-HMO DEDUCTIBLE

item

sequence: 1

revenue: 0551

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: 2020-09-29

location: HOME

adjudication

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

Amounts

-ValueCurrency
*84.4United States dollar

adjudication

category: Patient Co-Payment

Amounts

-ValueCurrency
*0United States dollar

adjudication

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

Amounts

-ValueCurrency
*56.52United States dollar

adjudication

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

Amounts

-ValueCurrency
*0United States dollar

adjudication

category: Amount payable under the coverage

Amounts

-ValueCurrency
*56.52United States dollar

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

-ValueCurrency
*0United States dollar

item

sequence: 2

revenue: 0023

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: 2020-09-29

location: HOME

adjudication

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

Amounts

-ValueCurrency
*0United States dollar

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

-ValueCurrency
*0United States dollar

Adjudications

-CategoryReason
*Benefit Payment StatusIn Network

total

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

Amounts

-ValueCurrency
*56.52United States dollar

total

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

Amounts

-ValueCurrency
*0United States dollar

total

category: Patient Co-Payment

Amounts

-ValueCurrency
*0United States dollar

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

-ValueCurrency
*0United States dollar

total

category: Amount payable under the coverage

Amounts

-ValueCurrency
*56.52United States dollar

total

category: The amount of the member's liability.

Amounts

-ValueCurrency
*0United States dollar
" }, "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" : "OutpatientEOBExample1" }], "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" : "outpatient" }], "text" : "Outpatient" }, "use" : "claim", "patient" : { "reference" : "Patient/Patient1" }, "billablePeriod" : { "start" : "2020-09-29", "end" : "2020-09-29" }, "created" : "2020-10-10T00:00:00-04:00", "insurer" : { "reference" : "Organization/Payer2", "display" : "UPMC Health Plan" }, "provider" : { "reference" : "Organization/ProviderOrganization5" }, "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/ProviderOrganization6" } }, "outcome" : "complete", "careTeam" : [{ "sequence" : 1, "provider" : { "reference" : "Practitioner/Practitioner1" }, "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/Practitioner3" }, "role" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "code" : "referring", "display" : "Referring" }], "text" : "The referring physician" } }], "supportingInfo" : [{ "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "clmrecvddate" }] }, "timingDate" : "2020-10-10" }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "I95.1" }] }, "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" : "I95.1" }] }, "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" : "L97.529" }] }, "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" : "I73.9" }] }, "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" }] }], "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/Coverage1" } }], "item" : [{ "sequence" : 1, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0551" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedDate" : "2020-09-29", "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "12" }], "text" : "HOME" }, "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "submitted", "display" : "Submitted Amount" }], "text" : "The total submitted amount for the claim or group or line item." }, "amount" : { "value" : 84.4, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "copay", "display" : "CoPay" }], "text" : "Patient Co-Payment" }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "eligible", "display" : "Eligible Amount" }], "text" : "Amount of the change which is considered for adjudication." }, "amount" : { "value" : 56.52, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "deductible", "display" : "Deductible" }], "text" : "Amount deducted from the eligible amount prior to adjudication." }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "benefit", "display" : "Benefit Amount" }], "text" : "Amount payable under the coverage" }, "amount" : { "value" : 56.52, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "noncovered", "display" : "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." }, "amount" : { "value" : 0, "currency" : "USD" } }] }, { "sequence" : 2, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0023" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "99231" }] }, "servicedDate" : "2020-09-29", "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "12" }], "text" : "HOME" }, "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "submitted", "display" : "Submitted Amount" }], "text" : "The total submitted amount for the claim or group or line item." }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "noncovered", "display" : "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." }, "amount" : { "value" : 0, "currency" : "USD" } }] }], "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" : "innetwork" }] } }], "total" : [{ "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "eligible", "display" : "Eligible Amount" }], "text" : "Amount of the change which is considered for adjudication." }, "amount" : { "value" : 56.52, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "deductible", "display" : "Deductible" }], "text" : "Amount deducted from the eligible amount prior to adjudication." }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "copay", "display" : "CoPay" }], "text" : "Patient Co-Payment" }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "noncovered", "display" : "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." }, "amount" : { "value" : 0, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "benefit", "display" : "Benefit Amount" }], "text" : "Amount payable under the coverage" }, "amount" : { "value" : 56.52, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "memberliability", "display" : "Member liability" }], "text" : "The amount of the member's liability." }, "amount" : { "value" : 0, "currency" : "USD" } }] }