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 |
{
"resourceType" : "ExplanationOfBenefit",
"id" : "EOBInpatient2",
"meta" : {
"lastUpdated" : "2020-04-28T15:39:36-04:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0-snapshot1"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit EOBInpatient2</b></p><a name=\"EOBInpatient2\"> </a><a name=\"hcEOBInpatient2\"> </a><a name=\"EOBInpatient2-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: 2020-04-28 15:39:36-0400</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional.html\">C4BB ExplanationOfBenefit Inpatient Institutionalversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/InpatientEOBExample1</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 inpatient}\">Inpatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)</a></p><p><b>billablePeriod</b>: 2017-05-23 --> 2017-05-23</p><p><b>created</b>: 2017-06-01 00:00:00-0400</p><p><b>insurer</b>: <a href=\"Organization-Payer2.html\">UPMC Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization3.html\">Organization Green Medical Group</a></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href=\"Organization-ProviderOrganization4.html\">Organization Blue Medical Group</a></td></tr></table><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Practitioner Jack Brown </a></p><p><b>role</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole attending}\">The attending physician</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Practitioner Jack Brown </a></p><p><b>role</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole referring}\">The referring physician</span></p></blockquote><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 admissionperiod}\">Admission Period</span></p><p><b>timing</b>: 2017-05-23 --> (ongoing)</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</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>: 2017-06-01</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm I21.4}\">Non-ST elevation (NSTEMI) myocardial infarction</span></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm I25.118}\">Athscl heart disease of native cor art w oth ang pctrs</span></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm E78.5}\">Hyperlipidemia, unspecified</span></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm M19.90}\">Unspecified osteoarthritis, unspecified site</span></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType principal}\">The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/ICD10 4A023N7}\">Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/ICD10 B211YZZ}\">Fluoroscopy of Multiple Coronary Arteries using Other Contrast</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/ICD10 B215YZZ}\">Fluoroscopy of Left Heart using Other Contrast</span></p></blockquote><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-Coverage2.html\">Coverage: identifier = An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.:\u00a088800933501; status = active; subscriberId = 888009335; dependent = 01; relationship = Self; period = 2017-01-01 --> 2017-06-30; network = GI8-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0301}\">0301</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0260}\">0260</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0305}\">0305</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0324}\">0324</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0259}\">0259</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0250}\">0250</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0710}\">0710</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0210}\">0210</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0272}\">0272</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0370}\">0370</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0730}\">0730</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0450}\">0450</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0481}\">0481</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 99231}\">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.</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>adjudication</b></p></blockquote><blockquote><p><b>adjudication</b></p></blockquote><blockquote><p><b>adjudication</b></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>7147.2</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1542.01</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication deductible}\">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication copay}\">Patient Co-Payment</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>120</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}\">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.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Amount payable under the coverage</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1393.57</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication memberliability}\">The amount of the member's liability.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc",
"display" : "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" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"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/Patient1"
},
"billablePeriod" : {
"start" : "2017-05-23",
"end" : "2017-05-23"
},
"created" : "2017-06-01T00:00:00-04:00",
"insurer" : {
🔗 "reference" : "Organization/Payer2",
"display" : "UPMC Health Plan"
},
"provider" : {
🔗 "reference" : "Organization/ProviderOrganization3"
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider",
"display" : "Provider"
}
],
"text" : "Any benefit payable will be paid to the provider (Assignment of Benefit)."
},
"party" : {
🔗 "reference" : "Organization/ProviderOrganization4"
}
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
🔗 "reference" : "Practitioner/Practitioner2"
},
"role" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code" : "attending",
"display" : "Attending"
}
],
"text" : "The attending physician"
}
},
{
"sequence" : 2,
"provider" : {
🔗 "reference" : "Practitioner/Practitioner2"
},
"role" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code" : "referring",
"display" : "Referring"
}
],
"text" : "The referring physician"
}
}
],
"supportingInfo" : [
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admissionperiod"
}
]
},
"timingPeriod" : {
"start" : "2017-05-23"
}
},
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate"
}
]
},
"timingDate" : "2017-06-01"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "I21.4"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal",
"display" : "Principal Diagnosis"
}
],
"text" : "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
}
]
},
{
"sequence" : 2,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "I25.118"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence" : 3,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "E78.5"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence" : 4,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "M19.90"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
}
],
"procedure" : [
{
"sequence" : 1,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "principal",
"display" : "Principal"
}
],
"text" : "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "4A023N7"
}
]
}
},
{
"sequence" : 2,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Other procedures performed during the inpatient institutional admission"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "B211YZZ"
}
]
}
},
{
"sequence" : 3,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Other procedures performed during the inpatient institutional admission"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "B215YZZ"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/Coverage2"
}
}
],
"item" : [
{
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0301"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 2,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0260"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 3,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0305"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 4,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0324"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 5,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0259"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 6,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0250"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 7,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0710"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 8,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0210"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 9,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0272"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 10,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0370"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 11,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0730"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 12,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0450"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 13,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0481"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
}
],
"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" : "outofnetwork"
}
]
}
},
{
"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",
"display" : "In Network"
}
],
"text" : "Indicates the provider was in network for the service"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "noncovered",
"display" : "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" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
],
"text" : "The total submitted amount for the claim or group or line item."
},
"amount" : {
"value" : 7147.2,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible",
"display" : "Eligible Amount"
}
],
"text" : "Amount of the change which is considered for adjudication."
},
"amount" : {
"value" : 1542.01,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "deductible",
"display" : "Deductible"
}
],
"text" : "Amount deducted from the eligible amount prior to adjudication."
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay",
"display" : "CoPay"
}
],
"text" : "Patient Co-Payment"
},
"amount" : {
"value" : 120,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "noncovered",
"display" : "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"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit",
"display" : "Benefit Amount"
}
],
"text" : "Amount payable under the coverage"
},
"amount" : {
"value" : 1393.57,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "memberliability",
"display" : "Member liability"
}
],
"text" : "The amount of the member's liability."
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
}
]
}
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
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