CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.2.0 - STU 2.2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOB Inpatient Example1

Page standards status: Informative

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "EOBInpatient1",
  "meta" : {
    "lastUpdated" : "2019-12-12T09:14:11+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.2.0"
    ]
  },
  "language" : "en",
  "text" : {
    "status" : "generated"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code" : "uc"
          }
        ]
      },
      "system" : "https://www.example.com/fhir/EOBIdentifier",
      "value" : "AW123412341234123412341234123412"
    }
  ],
  "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/Patient2"
  },
  "billablePeriod" : {
    "start" : "2019-01-01",
    "end" : "2019-10-31"
  },
  "created" : "2019-11-02T00:00:00+00:00",
  "insurer" : {
    🔗 "reference" : "Organization/Payer1",
    "display" : "XXX Health Plan"
  },
  "provider" : {
    🔗 "reference" : "Organization/ProviderOrganization1",
    "display" : "XXX Health Plan"
  },
  "outcome" : "partial",
  "supportingInfo" : [
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "admissionperiod"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2011-05-23",
        "end" : "2011-05-25"
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "clmrecvddate"
          }
        ]
      },
      "timingDate" : "2011-05-30"
    },
    {
      "sequence" : 4,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "typeofbill"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
            "code" : "Dummy"
          }
        ]
      }
    },
    {
      "sequence" : 5,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "pointoforigin"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/PointOfOrigin",
            "code" : "Dummy"
          }
        ]
      }
    },
    {
      "sequence" : 6,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "admtype"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit",
            "code" : "Dummy"
          }
        ]
      }
    },
    {
      "sequence" : 7,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "discharge-status"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/PatDischargeStatus",
            "code" : "11"
          }
        ]
      }
    },
    {
      "sequence" : 8,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "medicalrecordnumber"
          }
        ]
      },
      "valueString" : "1234-234-1243-12345678901m"
    },
    {
      "sequence" : 9,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "patientaccountnumber"
          }
        ]
      },
      "valueString" : "1234-234-1243-12345678901a"
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
            "code" : "S06.0X1A"
          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "version" : "1.0.1",
              "code" : "principal"
            }
          ]
        }
      ]
    }
  ],
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/Coverage3"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "revenue" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code" : "Dummy"
          }
        ]
      },
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/data-absent-reason",
            "version" : "1.0.0",
            "code" : "not-applicable",
            "display" : "Not Applicable"
          }
        ]
      },
      "servicedDate" : "2019-11-02"
    }
  ],
  "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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "billingnetworkstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidtoprovider"
          }
        ],
        "text" : "Payment Amount"
      },
      "amount" : {
        "value" : 620,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "version" : "1.0.1",
            "code" : "submitted"
          }
        ],
        "text" : "Submitted Amount"
      },
      "amount" : {
        "value" : 2650,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidbypatient"
          }
        ],
        "text" : "Patient Pay Amount"
      },
      "amount" : {
        "value" : 0,
        "currency" : "USD"
      }
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidtoprovider"
          }
        ],
        "text" : "Payment Amount"
      },
      "amount" : {
        "value" : 620,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "version" : "1.0.1",
            "code" : "submitted"
          }
        ],
        "text" : "Submitted Amount"
      },
      "amount" : {
        "value" : 2650,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidbypatient"
          }
        ],
        "text" : "Patient Pay Amount"
      },
      "amount" : {
        "value" : 0,
        "currency" : "USD"
      }
    }
  ]
}