Consumer-Directed Payer Data Exchange
- Release 0.1.0

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",
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              "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",
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              "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",
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              "display" : "Admitting Diagnosis"
            }
          ]
        }
      ],
      "onAdmission" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission",
            "code" : "y",
            "display" : "Yes"
          }
        ]
      }
    },
    {
      "sequence" : 7,
      "diagnosisCodeableConcept" : {
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          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
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          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
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            }
          ]
        }
      ],
      "onAdmission" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission",
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          }
        ]
      }
    }
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    {
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      "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",
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          }
        ]
      }
    },
    {
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              "system" : "http://terminology.hl7.org/CodeSystem/ex-procedure-type",
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          ]
        }
      ],
      "date" : "2017-04-07",
      "procedureCodeableConcept" : {
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            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
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            "display" : "Near Infrared Spectroscopy of Circulatory System, Percutaneous Approach"
          }
        ]
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    },
    {
      "sequence" : 4,
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          ]
        }
      ],
      "date" : "2017-04-08",
      "procedureCodeableConcept" : {
        "coding" : [
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            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
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          }
        ]
      }
    },
    {
      "sequence" : 5,
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          ]
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      ],
      "date" : "2017-04-09",
      "procedureCodeableConcept" : {
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          {
            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
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            "display" : "Release Right Hepatic Duct, Via Natural or Artificial Opening"
          }
        ]
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    },
    {
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        {
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            "display" : "Repair Left Hand Tendon, Percutaneous Approach"
          }
        ]
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    }
  ],
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/Coverage1"
      }
    }
  ],
  "item" : [
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        ]
      },
      "productOrService" : {
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        ]
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            "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"
  }
}