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" : "EOBProfessional1",
"meta" : {
"lastUpdated" : "2019-12-12T09:14:11+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.1.0-snapshot1"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit EOBProfessional1</b></p><a name=\"EOBProfessional1\"> </a><a name=\"hcEOBProfessional1\"> </a><a name=\"EOBProfessional1-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-Professional-NonClinician.html\">C4BB ExplanationOfBenefit Professional NonClinicianversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Unique Claim ID/AW123412341234123412341234123413</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</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.:\u00a088800933501)</a></p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-07-02 00:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">XXX Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">XXX Health Plan</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}\">Provider</span></td><td><a href=\"Organization-ProviderOrganization1.html\">Organization Orange Medical Group</a></td></tr></table><p><b>outcome</b>: Partial Processing</p><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 clmrecvddate}\">Claim Received Date</span></p><p><b>timing</b>: 2011-05-30</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 servicefacility}\">Service Facility</span></p><p><b>value</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization Orange Medical Group</a></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 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>: 6</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://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</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 --> 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 97110}\">Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility</span></p><p><b>serviced</b>: 2019-07-02</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}\">Office</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus other}\">Other</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</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>250</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</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>200</td><td>United States dollar</td></tr></table></blockquote></blockquote><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 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><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator renderingnetworkstatus}\">Rendering Network Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</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>250</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}\">Benefit Amount</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>200</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 paidtoprovider}\">Payment Amount</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>200</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 paidbypatient}\">Patient Pay Amount</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>payment</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus paid}\">Paid</span></p><h3>Adjustments</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>-50</td><td>United States dollar</td></tr></table><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>200</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"
}
]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123413"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
],
"text" : "Professional"
},
"use" : "claim",
"patient" : {
🔗 "reference" : "Patient/Patient2"
},
"billablePeriod" : {
"start" : "2019-01-01",
"end" : "2019-10-31"
},
"created" : "2019-07-02T00:00:00+00:00",
"insurer" : {
🔗 "reference" : "Organization/Payer1",
"display" : "XXX Health Plan"
},
"provider" : {
🔗 "reference" : "Organization/ProviderOrganization1",
"display" : "XXX Health Plan"
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider",
"display" : "Provider"
}
]
},
"party" : {
🔗 "reference" : "Organization/ProviderOrganization1"
}
},
"outcome" : "partial",
"supportingInfo" : [
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate"
}
]
},
"timingDate" : "2011-05-30"
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "servicefacility"
}
]
},
"valueReference" : {
🔗 "reference" : "Organization/ProviderOrganization1"
}
},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "medicalrecordnumber"
}
]
},
"valueString" : "1234-234-1243-12345678901m"
},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "patientaccountnumber"
}
]
},
"valueString" : "1234-234-1243-12345678901a"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "S06.0X1A"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/Coverage3"
}
}
],
"item" : [
{
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "97110",
"display" : "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility"
}
]
},
"servicedDate" : "2019-07-02",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11",
"display" : "Office"
}
]
},
"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" : "other"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 250,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
}
]
}
],
"adjudication" : [
{
"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"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code" : "renderingnetworkstatus"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 250,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
],
"text" : "Benefit Amount"
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
],
"text" : "Payment Amount"
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidbypatient"
}
],
"text" : "Patient Pay Amount"
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
}
],
"payment" : {
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "paid",
"display" : "Paid"
}
]
},
"adjustment" : {
"value" : -50,
"currency" : "USD"
},
"amount" : {
"value" : 200,
"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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