CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot
This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 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 
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="EOBOutpatientInstitutional1"/>
<meta>
<lastUpdated value="2019-12-12T09:14:11+00:00"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|1.2.0"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative</b></p><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">Resource "EOBOutpatientInstitutional1" Updated "2019-12-12T09:14:11Z" (Language "en-US") </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Outpatient-Institutional.html">C4BB ExplanationOfBenefit Outpatient Institutional (version 1.2.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>subType</b>: Outpatient <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBInstitutionalClaimSubType.html">C4BB Institutional Claim SubType</a>#outpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-Patient1.html">Patient/Patient1</a> " EXAMPLE1"</p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-11-02T00:00:00Z</p><p><b>insurer</b>: <a href="Organization-Payer1.html">Organization/Payer1: XXX Health Plan</a> "Payer 1"</p><p><b>provider</b>: <a href="Organization-OrganizationProvider1.html">Organization/OrganizationProvider1: XXX Health Plan</a> "Provider 1"</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Billing Network Contracting Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#billingnetworkcontractingstatus)</span></p><p><b>code</b>: Contracted <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#contracted)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Claim Received Date <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#clmrecvddate)</span></p><p><b>timing</b>: 2019-11-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Type of Bill <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#typeofbill)</span></p><p><b>code</b>: Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCTypeOfBill.html">NUBC Type Of Bill Codes</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Point Of Origin <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#pointoforigin)</span></p><p><b>code</b>: Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn.html">NUBC Point Of Origin for Non-newborn</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Admission Type <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#admtype)</span></p><p><b>code</b>: Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCPriorityTypeOfAdmissionOrVisit.html">NUBC Priority (Type) of Admission or Visit</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Discharge Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#discharge-status)</span></p><p><b>code</b>: Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCPatientDischargeStatus.html">NUBC Patient Discharge Status Codes</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Medical Record Number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#medicalrecordnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Patient Account Number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#patientaccountnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td>Concussion w LOC of 30 minutes or less, init <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.0X1A)</span></td><td>Patient Reason for Visit <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimDiagnosisType.html">C4BB Claim Diagnosis Type</a>#patientreasonforvisit)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-Coverage1.html">Coverage/Coverage1</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td>*</td><td>1</td><td>Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#Dummy)</span></td><td>Not Applicable <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-data-absent-reason.html">DataAbsentReason</a>#not-applicable)</span></td><td>2019-11-02</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: Payment Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#paidtoprovider)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Pay Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#paidbypatient)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#paidtoprovider)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#paidbypatient)</span></p></blockquote></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
<code value="uc"/>
</coding>
</type>
<system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
<value value="AW123412341234123412341234123412"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
</coding>
<text value="Institutional"/>
</type>
<subType>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
<code value="outpatient"/>
</coding>
<text value="Outpatient"/>
</subType>
<use value="claim"/>
<patient>
<reference value="Patient/Patient1"/>
</patient>
<billablePeriod>
<start value="2019-01-01"/>
<end value="2019-10-31"/>
</billablePeriod>
<created value="2019-11-02T00:00:00+00:00"/>
<insurer>
<reference value="Organization/Payer1"/>
<display value="XXX Health Plan"/>
</insurer>
<provider>
<reference value="Organization/OrganizationProvider1"/>
<display value="XXX Health Plan"/>
</provider>
<outcome value="partial"/>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="billingnetworkcontractingstatus"/>
</coding>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="clmrecvddate"/>
</coding>
</category>
<timingDate value="2019-11-30"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="typeofbill"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="pointoforigin"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/PointOfOrigin"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="admtype"/>
</coding>
</category>
<code>
<coding>
<system
value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="discharge-status"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/CodeSystem/PatDischargeStatus"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="7"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="medicalrecordnumber"/>
</coding>
</category>
<valueString value="1234-234-1243-12345678901m"/>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="patientaccountnumber"/>
</coding>
</category>
<valueString value="1234-234-1243-12345678901a"/>
</supportingInfo>
<supportingInfo>
<sequence value="9"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</category>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.0X1A"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
<code value="patientreasonforvisit"/>
</coding>
</type>
</diagnosis>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/Coverage1"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="Dummy"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
<code value="not-applicable"/>
<display value="Not Applicable"/>
</coding>
</productOrService>
<servicedDate value="2019-11-02"/>
</item>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="paidtoprovider"/>
</coding>
<text value="Payment Amount"/>
</category>
<amount>
<value value="620"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="paidbypatient"/>
</coding>
<text value="Patient Pay Amount"/>
</category>
<amount>
<value value="0"/>
</amount>
</adjudication>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="paidtoprovider"/>
</coding>
<text value="Payment Amount"/>
</category>
<amount>
<value value="620"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
<text value="Submitted Amount"/>
</category>
<amount>
<value value="2650"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="paidbypatient"/>
</coding>
<text value="Patient Pay Amount"/>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>
IG © 2021+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.2.0 based on FHIR 4.0.1. Generated 2021-12-06
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