{ "resourceType" : "ExplanationOfBenefit", "id" : "EOBProfessionalTransportation1", "meta" : { "lastUpdated" : "2022-09-10T14:46:05-04:00", "profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.2.0"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: ExplanationOfBenefit EOBProfessionalTransportation1

Last updated: 2022-09-10 14:46:05-0400; Language: en

Profile: C4BB ExplanationOfBenefit Professional NonClinicianversion: null2.2.0)

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

use: Claim

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

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

created: 2022-09-10 14:46:05-0400

insurer: UPMC Health Plan

provider: Organization ABC Ambulance Services

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit).Organization ABC Ambulance Services

outcome: Processing Complete

supportingInfo

sequence: 1

category: Date the claim was received by the payer.

timing: 2022-09-11

supportingInfo

sequence: 2

category: Patient Weight

value: 160 [lb_av]

supportingInfo

sequence: 3

category: Ambulance Transport Reason

reason: ambulance-transport-reason-codes: B (Patient was transported for the benefit of a preferred physician)

supportingInfo

sequence: 4

category: Transportation Distance

value: 21 [mi_i]

supportingInfo

sequence: 5

category: Transportation Distance

value: 22 [mi_i]

supportingInfo

sequence: 6

category: Round Trip Purpose

value: Trip to facility and then back home

supportingInfo

sequence: 7

category: Stretcher Purpose

value: Patient could not walk

supportingInfo

sequence: 8

category: Pick-up Location

value: Patient home; Pittsburgh; PA,15222

supportingInfo

sequence: 9

category: Drop-off Location

value: Orange Medical Group; Pittsburgh; PA,15222

supportingInfo

sequence: 10

category: Pick-up Location

value: Orange Medical Group; Pittsburgh; PA,15222

supportingInfo

sequence: 11

category: Drop-off Location

value: Patient home; Pittsburgh; PA,15222

Diagnoses

-SequenceDiagnosis[x]Type
*1Athscl native arteries of left leg w ulceration of unsp siteThe single medical diagnosis that is most relevant to the patient's chief complaint or need for 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

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

productOrService: Ambulance service, basic life support, non-emergency transport (BLS)

serviced: 2022-09-10

location: Ambulance - Land

adjudication

category: Benefit Payment Status

reason: In Network

adjudication

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

Amounts

-ValueCurrency
*40.35United States dollar

adjudication

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

Amounts

-ValueCurrency
*40.35United 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
*40.35United States dollar

item

sequence: 2

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

productOrService: Ambulance service, basic life support, non-emergency transport (BLS)

serviced: 2022-09-10

location: Ambulance - Land

adjudication

category: Benefit Payment Status

reason: In Network

adjudication

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

Amounts

-ValueCurrency
*42.62United States dollar

adjudication

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

Amounts

-ValueCurrency
*42.62United 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
*42.62United States dollar

Adjudications

-CategoryReason
*Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.Indicates the provider was in network for the service

total

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

Amounts

-ValueCurrency
*82.97United States dollar

total

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

Amounts

-ValueCurrency
*82.97United States dollar

total

category: Amount payable under the coverage

Amounts

-ValueCurrency
*82.97United 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" : "ProfessionalTransportationEOBExample1" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "version" : "1.0.1", "code" : "professional" }], "text" : "Professional" }, "use" : "claim", "patient" : { "reference" : "Patient/Patient1" }, "billablePeriod" : { "start" : "2022-09-10" }, "created" : "2022-09-10T14:46:05-04:00", "insurer" : { "reference" : "Organization/Payer2", "display" : "UPMC Health Plan" }, "provider" : { "reference" : "Organization/ProviderTransportationOrganization1" }, "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/ProviderTransportationOrganization1" } }, "outcome" : "complete", "supportingInfo" : [{ "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "clmrecvddate", "display" : "Claim Received Date" }], "text" : "Date the claim was received by the payer." }, "timingDate" : "2022-09-11" }, { "sequence" : 2, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "patientweight" }] }, "valueQuantity" : { "value" : 160, "unit" : "[lb_av]", "system" : "http://unitsofmeasure.org" } }, { "sequence" : 3, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "ambulancetransportreason" }] }, "reason" : { "system" : "https://x12.org/codesystem.x12.org/ambulance-transport-reason-codes", "code" : "B", "display" : "Patient was transported for the benefit of a preferred physician" } }, { "sequence" : 4, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "transportationdistance" }] }, "valueQuantity" : { "value" : 21, "unit" : "[mi_i]", "system" : "http://unitsofmeasure.org" } }, { "sequence" : 5, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "transportationdistance" }] }, "valueQuantity" : { "value" : 22, "unit" : "[mi_i]", "system" : "http://unitsofmeasure.org" } }, { "sequence" : 6, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "roudtrippurpose" }] }, "valueString" : "Trip to facility and then back home" }, { "sequence" : 7, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "stretcherpurpose" }] }, "valueString" : "Patient could not walk" }, { "sequence" : 8, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "pickuplocation" }] }, "valueString" : "Patient home; Pittsburgh; PA,15222" }, { "sequence" : 9, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "dropofflocation" }] }, "valueString" : "Orange Medical Group; Pittsburgh; PA,15222" }, { "sequence" : 10, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "pickuplocation" }] }, "valueString" : "Orange Medical Group; Pittsburgh; PA,15222" }, { "sequence" : 11, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "dropofflocation" }] }, "valueString" : "Patient home; Pittsburgh; PA,15222" }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "I70.249" }] }, "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." }] }], "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/Coverage1" } }], "item" : [{ "sequence" : 1, "informationSequence" : [2, 3, 4, 6, 7, 10, 11], "productOrService" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", "code" : "A0428", "display" : "Ambulance service, basic life support, non-emergency transport (BLS)" }] }, "servicedDate" : "2022-09-10", "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "41" }], "text" : "Ambulance - Land" }, "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" }] } }, { "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" : 40.35, "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" : 40.35, "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" : 40.35, "currency" : "USD" } }] }, { "sequence" : 2, "informationSequence" : [2, 3, 5, 6, 7, 8, 9], "productOrService" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", "code" : "A0428", "display" : "Ambulance service, basic life support, non-emergency transport (BLS)" }] }, "servicedDate" : "2022-09-10", "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "41" }], "text" : "Ambulance - Land" }, "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" }] } }, { "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" : 42.62, "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" : 42.62, "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" : 42.62, "currency" : "USD" } }] }], "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "billingnetworkstatus", "display" : "Billing Network Status" }], "text" : "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." }, "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" } }], "total" : [{ "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" : 82.97, "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" : 82.97, "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" : 82.97, "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" } }] }