This page is part of the CARIN Blue Button Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions
JSON Format: ExplanationOfBenefit-EOB1
Raw json
{ "resourceType" : "ExplanationOfBenefit", "id" : "EOB1", "meta" : { "versionId" : "4", "lastUpdated" : "2019-12-18T22:49:23.000-05:00", "profile" : [ "http://hl7.org/fhir/us/carin/StructureDefinition/carin-bb-explanationofbenefit" ] }, "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n\t\t\t<p>\n\t\t\t\t<b>Generated Narrative with Details</b>\n\t\t\t</p>\n\t\t\t</div>" }, "identifier" : [ { "system" : "http://www.bcbs.com/fhir/ns/NamingSystem/explanationOfBenefit-identifier", "value" : "4E93-BE91-EAC1977941A8" } ], "status" : "active", "type" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claim-type", "code" : "inpatient-facility", "display" : "Inpatient Facility" } ] }, "use" : "claim", "patient" : { "reference" : "Patient/Patient1" }, "billablePeriod" : { "start" : "2017-04-05", "end" : "2017-04-14" }, "created" : "2017-04-15", "insurer" : { "reference" : "Organization/Org45" }, "provider" : { "reference" : "Organization/Org1" }, "outcome" : "complete", "careTeam" : [ { "sequence" : 1, "provider" : { "reference" : "PractitionerRole/PractitionerRole1" }, "responsible" : true, "role" : { "coding" : [ { "code" : "supervising", "display" : "Attending or Supervising provider" } ] } }, { "sequence" : 2, "provider" : { "reference" : "PractitionerRole/PractitionerRole1" }, "responsible" : false, "role" : { "coding" : [ { "code" : "performing", "display" : "Servicing or Rendering provider" } ] } }, { "sequence" : 3, "provider" : { "reference" : "PractitionerRole/PractitionerRole1" }, "responsible" : false, "role" : { "coding" : [ { "code" : "prescribing", "display" : "Prescribing provider" } ] } } ], "supportingInfo" : [ { "sequence" : 1, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "billingnetworkcontractingstatus" } ] } }, { "sequence" : 2, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "attendingnetworkcontractingstatus" } ] } }, { "sequence" : 3, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "clmrecvddate" } ] }, "timingDate" : "2017-04-12" }, { "sequence" : 4, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "typeofservice" } ] } }, { "sequence" : 5, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "tob-typeoffacility" } ] } }, { "sequence" : 6, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "tob-billclassification" } ] } }, { "sequence" : 7, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "tob-frequency" } ] } }, { "sequence" : 8, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory", "code" : "admsrc" } ] } } ], "diagnosis" : [ { "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "A30.1", "display" : "Tuberculoid leprosy" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "principal", "display" : "Principal diagnosis" } ] } ] }, { "sequence" : 2, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "S40.861A", "display" : "Diagnosis description 1" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "principal", "display" : "Principal diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "y", "display" : "Yes" } ] } }, { "sequence" : 3, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "A05.1" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "admitting", "display" : "Admitting Diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "n", "display" : "No" } ] } }, { "sequence" : 4, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "A37.00" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "admitting", "display" : "Admitting Diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "y", "display" : "Yes" } ] } }, { "sequence" : 5, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "G44.221" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "admitting", "display" : "Admitting Diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "u", "display" : "Unknown" } ] } }, { "sequence" : 6, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "I11.9" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "admitting", "display" : "Admitting Diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "y", "display" : "Yes" } ] } }, { "sequence" : 7, "diagnosisCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "A31.1" } ] }, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code" : "admitting", "display" : "Admitting Diagnosis" } ] } ], "onAdmission" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission", "code" : "y", "display" : "Yes" } ] } } ], "procedure" : [ { "sequence" : 1, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type", "code" : "primary" } ] } ], "date" : "2017-04-05", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "3E00X28", "display" : "Introduction of Oxazolidinones into Skin and Mucous Membranes, External Approach" } ] } }, { "sequence" : 2, "date" : "2017-04-06", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "8E01XY7", "display" : "Examination of Nervous System" } ] } }, { "sequence" : 3, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type", "code" : "secondary" } ] } ], "date" : "2017-04-07", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "8E023DZ", "display" : "Near Infrared Spectroscopy of Circulatory System, Percutaneous Approach" } ] } }, { "sequence" : 4, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type", "code" : "secondary" } ] } ], "date" : "2017-04-08", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "02114A3", "display" : "Bypass Coronary Artery, Two Arteries from Coronary Artery with Autologous Arterial Tissue, Percutaneous Endoscopic Approach" } ] } }, { "sequence" : 5, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type", "code" : "secondary" } ] } ], "date" : "2017-04-09", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "0FN57ZZ", "display" : "Release Right Hepatic Duct, Via Natural or Artificial Opening" } ] } }, { "sequence" : 6, "type" : [ { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type", "code" : "secondary" } ] } ], "date" : "2017-04-10", "procedureCodeableConcept" : { "coding" : [ { "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures", "code" : "0LQ83ZZ", "display" : "Repair Left Hand Tendon, Percutaneous Approach" } ] } } ], "insurance" : [ { "focal" : true, "coverage" : { "reference" : "Coverage/Coverage1" } } ], "item" : [ { "sequence" : 1, "careTeamSequence" : [ 1 ], "diagnosisSequence" : [ 2 ], "procedureSequence" : [ 1 ], "informationSequence" : [ 1 ], "revenue" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center", "code" : "0450" } ] }, "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code" : "1", "display" : "Medical Care" } ] }, "productOrService" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code" : "1101", "display" : "Exam, comp, primary" } ] }, "quantity" : { "value" : 6 }, "adjudication" : [ { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" } ] }, "amount" : { "value" : 8000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" } ] }, "amount" : { "value" : 8000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "deductible" } ] }, "amount" : { "value" : 5000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "copay" } ] }, "amount" : { "value" : 100 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" } ] }, "amount" : { "value" : 2400 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "tax" } ] }, "amount" : { "value" : 0 } } ] }, { "sequence" : 2, "careTeamSequence" : [ 1 ], "diagnosisSequence" : [ 2 ], "procedureSequence" : [ 1 ], "informationSequence" : [ 1 ], "revenue" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center", "code" : "0450" } ] }, "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code" : "1", "display" : "Medical Care" } ] }, "productOrService" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code" : "1101", "display" : "Exam, comp, primary" } ] }, "quantity" : { "value" : 2 }, "adjudication" : [ { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" } ] }, "amount" : { "value" : 750 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" } ] }, "amount" : { "value" : 0 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "deductible" } ] }, "amount" : { "value" : 750 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" } ] }, "amount" : { "value" : 0 } }, { "category" : { "text" : "copay" }, "amount" : { "value" : 750 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "tax" } ] }, "amount" : { "value" : 0 } } ] }, { "sequence" : 3, "careTeamSequence" : [ 1 ], "diagnosisSequence" : [ 2 ], "procedureSequence" : [ 1 ], "informationSequence" : [ 1 ], "revenue" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center", "code" : "0370" } ] }, "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code" : "1", "display" : "Medical Care" } ] }, "productOrService" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code" : "1205", "display" : "Exam, emergency" } ] }, "quantity" : { "value" : 2 }, "adjudication" : [ { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" } ] }, "amount" : { "value" : 250 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" } ] }, "amount" : { "value" : 0 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "deductible" } ] }, "amount" : { "value" : 250 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" } ] }, "amount" : { "value" : 0 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "copay" } ] }, "amount" : { "value" : 250 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "tax" } ] }, "amount" : { "value" : 0 } } ] } ], "adjudication" : [ { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" } ] }, "amount" : { "value" : 9000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" } ] }, "amount" : { "value" : 8000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "deductible" } ] }, "amount" : { "value" : 5000 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "copay" } ] }, "amount" : { "value" : 100 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" } ] }, "amount" : { "value" : 2400 } }, { "category" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "tax" } ] }, "amount" : { "value" : 0 } } ], "total" : [ { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "submittedamount" } ] }, "amount" : { "value" : 9000 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "allowedamount" } ] }, "amount" : { "value" : 8000 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "deductibleamount" } ] }, "amount" : { "value" : 5000 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "coinsuranceamount" } ] }, "amount" : { "value" : 80 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "copayamount" } ] }, "amount" : { "value" : 100 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "noncoveredamount" } ] }, "amount" : { "value" : 1000 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "paymentamount" } ] }, "amount" : { "value" : 2400 } }, { "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory", "code" : "patientpayamount" } ] }, "amount" : { "value" : 6600 } } ], "payment" : { "type" : { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype", "code" : "partial" } ] }, "date" : "2017-05-12" } }