CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft
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
| Page standards status: Informative |
Generated Narrative: ExplanationOfBenefit BB-EOBProfessionalTransportation1-nonfinancial
Last updated: 2022-09-10 14:46:05-0400;
Information Source: Organization/PayerOrganizationExample1
Profile: C4BB ExplanationOfBenefit Professional NonClinician Basisversion: {0}2.1.0-snapshot1)
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
| Type | Party |
| 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: X12 Ambulance Transport Reason Codes Code System 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
| Sequence | Diagnosis[x] | Type |
| 1 | Athscl native arteries of left leg w ulceration of unsp site | The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. |
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
Adjudications
Category Reason Benefit Payment Status In Network
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
Adjudications
Category Reason Benefit Payment Status In Network
| Category | Reason |
| 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
Value Currency 82.97 United States dollar
total
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 82.97 United States dollar
total
category: Amount payable under the coverage
Amounts
Value Currency 82.97 United States dollar
total
category: The amount of the member's liability.
Amounts
Value Currency 0 United States dollar
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0-snapshot1 based on FHIR 4.0.1. Generated 2024-07-27
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change