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

: EOB Outpatient Institutional - Example 1 - Nonfinancial - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="BB-EOBOutpatient1-nonfinancial"/>
  <meta>
    <lastUpdated value="2019-12-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional-Basis|2.1.0-snapshot1"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit BB-EOBOutpatient1-nonfinancial</b></p><a name="BB-EOBOutpatient1-nonfinancial"> </a><a name="hcBB-EOBOutpatient1-nonfinancial"> </a><a name="BB-EOBOutpatient1-nonfinancial-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2019-12-12 09:14:11+0000; Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Outpatient-Institutional-Basis.html">C4BB ExplanationOfBenefit Outpatient Institutional Basisversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Unique Claim ID/AW123412341234123412341234123412</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>subType</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType outpatient}">Outpatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">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)</a></p><p><b>billablePeriod</b>: 2019-01-01 --&gt; 2019-10-31</p><p><b>created</b>: 2019-11-02 00:00:00+0000</p><p><b>insurer</b>: <a href="Organization-Payer1.html">Organization Payer 1</a></p><p><b>provider</b>: <a href="Organization-ProviderOrganization1.html">Orange Medical Group</a></p><p><b>outcome</b>: Partial Processing</p><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Organization-ProviderOrganization1.html">Organization Orange Medical Group</a></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole rendering}">Rendering provider</span></td><td><span title="Codes:{http://nucc.org/provider-taxonomy 364SX0200X}">Oncology Clinical Nurse Specialist</span></td></tr></table><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Claim Received Date</span></p><p><b>timing</b>: 2019-11-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType typeofbill}">Type of Bill</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/TypeOfBill Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType pointoforigin}">Point Of Origin</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PointOfOrigin Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admtype}">Admission Type</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType discharge-status}">Discharge Status</span></p><p><b>code</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/PatDischargeStatus Dummy}">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType medicalrecordnumber}">Medical Record Number</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientaccountnumber}">Patient Account Number</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.0X1A}">Concussion w LOC of 30 minutes or less, init</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType patientreasonforvisit}">Patient Reason for Visit</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Coverage-Coverage3.html">Coverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --&gt; 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes Dummy}">Dummy</span></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/data-absent-reason not-applicable}">Not Applicable</span></td><td>2019-11-02</td></tr></table><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}">Billing Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr></table></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
    <value value="AW123412341234123412341234123412"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
    <text value="Institutional"/>
  </type>
  <subType>
    <coding>
      <system
              value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
      <code value="outpatient"/>
    </coding>
    <text value="Outpatient"/>
  </subType>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient2"/>
  </patient>
  <billablePeriod>
    <start value="2019-01-01"/>
    <end value="2019-10-31"/>
  </billablePeriod>
  <created value="2019-11-02T00:00:00+00:00"/>
  <insurer>🔗 
    <reference value="Organization/Payer1"/>
    <display value="Organization Payer 1"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ProviderOrganization1"/>
    <display value="Orange Medical Group"/>
  </provider>
  <outcome value="partial"/>
  <careTeam>
    <sequence value="1"/>
    <provider>🔗 
      <reference value="Organization/ProviderOrganization1"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="rendering"/>
        <display value="Rendering provider"/>
      </coding>
    </role>
    <qualification>
      <coding>
        <system value="http://nucc.org/provider-taxonomy"/>
        <code value="364SX0200X"/>
        <display value="Oncology Clinical Nurse Specialist"/>
      </coding>
    </qualification>
  </careTeam>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2019-11-30"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="typeofbill"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="4"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="pointoforigin"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/PointOfOrigin"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="5"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="admtype"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="6"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="discharge-status"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/PatDischargeStatus"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="7"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="medicalrecordnumber"/>
      </coding>
    </category>
    <valueString value="1234-234-1243-12345678901m"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="8"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="patientaccountnumber"/>
      </coding>
    </category>
    <valueString value="1234-234-1243-12345678901a"/>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="S06.0X1A"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="patientreasonforvisit"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/Coverage3"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="Dummy"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
        <code value="not-applicable"/>
        <display value="Not Applicable"/>
      </coding>
    </productOrService>
    <servicedDate value="2019-11-02"/>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
</ExplanationOfBenefit>