EOB Inpatient Example 2 - CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) v2.1.0-snapshot1

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 Example 2

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit EOBInpatient2

Last updated: 2020-04-28 15:39:36-0400

Profile: C4BB ExplanationOfBenefit Inpatient Institutionalversion: {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/InpatientEOBExample1

status: Active

type: Institutional

subType: Inpatient

use: Claim

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

billablePeriod: 2017-05-23 --> 2017-05-23

created: 2017-06-01 00:00:00-0400

insurer: UPMC Health Plan

provider: Organization Green Medical Group

Payees

Type

Party

Any benefit payable will be paid to the provider (Assignment of Benefit).

Organization Blue Medical Group

outcome: Processing Complete

careTeam
sequence: 1
provider: Practitioner Jack Brown
role: The attending physician

careTeam
sequence: 2
provider: Practitioner Jack Brown
role: The referring physician

supportingInfo
sequence: 2
category: Admission Period
timing: 2017-05-23 --> (ongoing)

supportingInfo
sequence: 1
category: Claim Received Date
timing: 2017-06-01

diagnosis
sequence: 1
diagnosis: Non-ST elevation (NSTEMI) myocardial infarction
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.

diagnosis
sequence: 2
diagnosis: Athscl heart disease of native cor art w oth ang pctrs
type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis
sequence: 3
diagnosis: Hyperlipidemia, unspecified
type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis
sequence: 4
diagnosis: Unspecified osteoarthritis, unspecified site
type: Required when other conditions coexist or develop subsequently during the treatment

procedure
sequence: 1
type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis
date: 2017-05-23
procedure: Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach

procedure
sequence: 2
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: Fluoroscopy of Multiple Coronary Arteries using Other Contrast

procedure
sequence: 3
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: Fluoroscopy of Left Heart using Other Contrast

Insurances

Focal

Coverage

true

Coverage: identifier = An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status = active; subscriberId = 888009335; dependent = 01; relationship = Self; period = 2017-01-01 --> 2017-06-30; network = GI8-HMO DEDUCTIBLE

item
sequence: 1
revenue: 0301
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 2
revenue: 0260
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 3
revenue: 0305
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 4
revenue: 0324
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 5
revenue: 0259
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 6
revenue: 0250
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 7
revenue: 0710
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 8
revenue: 0210
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 9
revenue: 0272
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 10
revenue: 0370
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 11
revenue: 0730
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 12
revenue: 0450
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

item
sequence: 13
revenue: 0481
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL

adjudication

total
category: The total submitted amount for the claim or group or line item.
Amounts
- Value Currency
* 7147.2 United States dollar

total
category: Amount of the change which is considered for adjudication.
Amounts
- Value Currency
* 1542.01 United States dollar

total
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- Value Currency
* 0 United States dollar

total
category: Patient Co-Payment
Amounts
- Value Currency
* 120 United States dollar

total
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- Value Currency
* 0 United States dollar

total
category: Amount payable under the coverage
Amounts
- Value Currency
* 1393.57 United States dollar

total
category: The amount of the member's liability.
Amounts
- Value Currency
* 0 United States dollar

Notes:

Instance: EOBInpatient2
InstanceOf: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0-snapshot1
Title: "EOB Inpatient Example 2"
Description: "EOB Inpatient Example 2"
Usage: #example
* meta.lastUpdated = "2020-04-28T15:39:36-04:00"
* identifier
  * type = C4BBIdentifierType#uc "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.upmchealthplan.com/fhir/EOBIdentifier"
  * value = "InpatientEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
  * text = "Institutional"
* subType = C4BBInstitutionalClaimSubType#inpatient
  * text = "Inpatient"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod
  * start = "2017-05-23"
  * end = "2017-05-23"
* created = "2017-06-01T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization3)
* payee
  * type = http://terminology.hl7.org/CodeSystem/payeetype#provider "Provider"
    * text = "Any benefit payable will be paid to the provider (Assignment of Benefit)."
  * party = Reference(ProviderOrganization4)
* outcome = #complete
* careTeam[0]
  * sequence = 1
  * provider = Reference(Practitioner2)
  * role = C4BBClaimCareTeamRole#attending "Attending"
    * text = "The attending physician"
* careTeam[+]
  * sequence = 2
  * provider = Reference(Practitioner2)
  * role = C4BBClaimCareTeamRole#referring "Referring"
    * text = "The referring physician"
* supportingInfo[0]
  * sequence = 2
  * category = C4BBSupportingInfoType#admissionperiod
  * timingPeriod.start = "2017-05-23"
* supportingInfo[+]
  * sequence = 1
  * category = C4BBSupportingInfoType#clmrecvddate
  * timingDate = "2017-06-01"
* diagnosis[0]
  * sequence = 1
  * diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I21.4
  * type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal "Principal Diagnosis"
    * text = "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
* diagnosis[+]
  * sequence = 2
  * diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I25.118
  * type = C4BBClaimDiagnosisType#other "Other"
    * text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+]
  * sequence = 3
  * diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#E78.5
  * type = C4BBClaimDiagnosisType#other "Other"
    * text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+]
  * sequence = 4
  * diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#M19.90
  * type = C4BBClaimDiagnosisType#other "Other"
    * text = "Required when other conditions coexist or develop subsequently during the treatment"
* procedure[0]
  * sequence = 1
  * type = C4BBClaimProcedureType#principal "Principal"
    * text = "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
  * date = "2017-05-23"
  * procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#4A023N7
* procedure[+]
  * sequence = 2
  * type = C4BBClaimProcedureType#other "Other"
    * text = "Other procedures performed during the inpatient institutional admission"
  * date = "2017-05-23"
  * procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#B211YZZ
* procedure[+]
  * sequence = 3
  * type = C4BBClaimProcedureType#other "Other"
    * text = "Other procedures performed during the inpatient institutional admission"
  * date = "2017-05-23"
  * procedureCodeableConcept = http://www.cms.gov/Medicare/Coding/ICD10#B215YZZ
* insurance
  * focal = true
  * coverage = Reference(Coverage2)
* item[0]
  * sequence = 1
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0301
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 2
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0260
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 3
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0305
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 4
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0324
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 5
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0259
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 6
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0250
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 7
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0710
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 8
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0210
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 9
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0272
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 10
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0370
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 11
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0730
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 12
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0450
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* item[+]
  * sequence = 13
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0481
  * productOrService = http://www.ama-assn.org/go/cpt#99231
  * servicedPeriod.start = "2017-05-23"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
    * text = "HOSPITAL - INPATIENT HOSPITAL"
* adjudication[0]
  * category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
  * reason = C4BBPayerAdjudicationStatus#outofnetwork
* adjudication[+]
  * category = C4BBAdjudicationDiscriminator#billingnetworkstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork "In Network"
    * text = "Indicates the provider was in network for the service"
* adjudication[+]
  * category = C4BBAdjudication#noncovered "Noncovered"
    * text = "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
  * amount
    * value = 0
    * currency = #USD
* total[0]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
    * text = "The total submitted amount for the claim or group or line item."
  * amount
    * value = 7147.2
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
    * text = "Amount of the change which is considered for adjudication."
  * amount
    * value = 1542.01
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
    * text = "Amount deducted from the eligible amount prior to adjudication."
  * amount
    * value = 0
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#copay "CoPay"
    * text = "Patient Co-Payment"
  * amount
    * value = 120
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#noncovered "Noncovered"
    * text = "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
  * amount
    * value = 0
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
    * text = "Amount payable under the coverage"
  * amount
    * value = 1393.57
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#memberliability "Member liability"
    * text = "The amount of the member's liability."
  * amount
    * value = 0
    * currency = #USD