CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0-snapshot1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Inpatient Institutional - Example 1 - Nonfinancial

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit BB-EOBInpatient1-nonfinancial

Last updated: 2019-12-12 09:14:11+0000; Language: en-US

Profile: C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: {0}2.1.0-snapshot1)

identifier: Unique Claim ID/AW123412341234123412341234123412

status: Active

type: Institutional

subType: Inpatient

use: Claim

patient: Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)

billablePeriod: 2019-01-01 --> 2019-10-31

created: 2019-11-02 00:00:00+0000

insurer: XXX Health Plan

provider: XXX Health Plan

outcome: Partial Processing

supportingInfo

sequence: 2

category: Admission Period

timing: 2011-05-23 --> 2011-05-25

supportingInfo

sequence: 3

category: Claim Received Date

timing: 2011-05-30

supportingInfo

sequence: 4

category: Type of Bill

code: Dummy

supportingInfo

sequence: 5

category: Point Of Origin

code: Dummy

supportingInfo

sequence: 6

category: Admission Type

code: Dummy

supportingInfo

sequence: 7

category: Discharge Status

code: 11

supportingInfo

sequence: 8

category: Medical Record Number

value: 1234-234-1243-12345678901m

supportingInfo

sequence: 9

category: Patient Account Number

value: 1234-234-1243-12345678901a

Diagnoses

-SequenceDiagnosis[x]Type
*1Concussion w LOC of 30 minutes or less, initPrincipal Diagnosis

Insurances

-FocalCoverage
*trueCoverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --> 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA

Items

-SequenceRevenueProductOrServiceServiced[x]
*1DummyNot Applicable2019-11-02

Adjudications

-CategoryReason
*Benefit Payment StatusIn Network
*Billing Network StatusIn Network