Consumer-Directed Payer Data Exchange

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
XML Format: ExplanationOfBenefit-EOB1

Raw xml

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