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 
Generated Narrative
Resource "EOBProfessional1a" Updated "2019-12-12T09:14:11Z" (Language "en-US")
Profile: C4BB ExplanationOfBenefit Professional NonClinician (version 1.2.0)
identifier: Unique Claim ID: AW123412341234123412341234123413
status: active
type: Professional (Claim Type Codes#professional)
use: claim
patient: Patient/Patient1 " EXAMPLE1"
billablePeriod: 2019-01-01 --> 2019-10-31
created: 2019-07-02T00:00:00Z
insurer: Organization/Payer1: XXX Health Plan "Payer 1"
provider: Organization/OrganizationProvider1: XXX Health Plan "Provider 1"
outcome: partial
supportingInfo
sequence: 1
category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)
code: Contracted (C4BB Payer Adjudication Status#contracted)
supportingInfo
sequence: 2
category: Performing Network Contracting Status (C4BB Supporting Info Type#performingnetworkcontractingstatus)
code: Contracted (C4BB Payer Adjudication Status#contracted)
supportingInfo
sequence: 3
category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)
timing: 2011-05-30
supportingInfo
sequence: 4
category: Service Facility (C4BB Supporting Info Type#servicefacility)
value: Organization/OrganizationProvider1 "Provider 1"
supportingInfo
sequence: 5
category: Medical Record Number (C4BB Supporting Info Type#medicalrecordnumber)
value: 1234-234-1243-12345678901m
supportingInfo
sequence: 6
category: Patient Account Number (C4BB Supporting Info Type#patientaccountnumber)
value: 1234-234-1243-12345678901a
| - | Sequence | Diagnosis[x] | Type |
| * | 1 | Concussion w LOC of 30 minutes or less, init (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.0X1A) | Principal Diagnosis (Example Diagnosis Type Codes#principal) |
| - | Focal | Coverage |
| * | true | Coverage/Coverage1 |
item
sequence: 1
productOrService: Physical Therapy (Current Procedural Terminology (CPT®)#97110)
serviced: 2019-07-02
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
adjudication
category: Other (C4BB Payer Adjudication Status#other)
total
category: Payment Amount (C4BB Adjudication#paidtoprovider)
total
category: Submitted Amount (Adjudication Value Codes#submitted)
total
category: Patient Pay Amount (C4BB Adjudication#paidbypatient)
| Field | Value |
| resourceType | "ExplanationOfBenefit" |
| id | "EOBProfessional1a" |
| meta.profile[0] | "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" |
| meta.lastUpdated | "2019-12-12T09:14:11+00:00" |
| type.coding[0].code | #professional |
| type.coding[0].system | "http://terminology.hl7.org/CodeSystem/claim-type" |
| type.text | "Professional" |
| use | "claim" |
| supportingInfo[0].category.coding[0].code | #billingnetworkcontractingstatus |
| supportingInfo[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[0].code.coding[0].code | #contracted |
| supportingInfo[0].code.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| supportingInfo[0].sequence | 1 |
| supportingInfo[1].category.coding[0].code | #performingnetworkcontractingstatus |
| supportingInfo[1].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[1].code.coding[0].code | #contracted |
| supportingInfo[1].code.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| supportingInfo[1].sequence | 2 |
| supportingInfo[2].category.coding[0].code | #clmrecvddate |
| supportingInfo[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[2].timingDate | "2011-05-30" |
| supportingInfo[2].sequence | 3 |
| supportingInfo[3].category.coding[0].code | #servicefacility |
| supportingInfo[3].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[3].sequence | 4 |
| supportingInfo[3].valueReference.reference | "Organization/OrganizationProvider1" |
| supportingInfo[4].category.coding[0].code | #medicalrecordnumber |
| supportingInfo[4].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[4].valueString | "1234-234-1243-12345678901m" |
| supportingInfo[4].sequence | 5 |
| supportingInfo[5].category.coding[0].code | #patientaccountnumber |
| supportingInfo[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[5].valueString | "1234-234-1243-12345678901a" |
| supportingInfo[5].sequence | 6 |
| language | "en-US" |
| status | "active" |
| identifier[0].type.coding[0].code | #uc |
| identifier[0].type.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" |
| identifier[0].value | AW123412341234123412341234123413 |
| identifier[0].system | "https://www.xxxplan.com/fhir/EOBIdentifier" |
| created | "2019-07-02T00:00:00+00:00" |
| insurer.reference | "Organization/Payer1" |
| insurer.display | "XXX Health Plan" |
| patient.reference | "Patient/Patient1" |
| billablePeriod.start | "2019-01-01" |
| billablePeriod.end | "2019-10-31" |
| provider.reference | "Organization/OrganizationProvider1" |
| provider.display | "XXX Health Plan" |
| outcome | "partial" |
| diagnosis[0].diagnosisCodeableConcept.coding[0].code | #S06.0X1A |
| diagnosis[0].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[0].type[0].coding[0].code | #principal |
| diagnosis[0].type[0].coding[0].system | "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" |
| diagnosis[0].sequence | 1 |
| insurance[0].focal | "true" |
| insurance[0].coverage.reference | "Coverage/Coverage1" |
| total[0].category.coding[0].code | #paidtoprovider |
| total[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[0].category.text | "Payment Amount" |
| total[0].amount.value | 620 |
| total[0].amount.currency | #USD |
| total[1].category.coding[0].code | #submitted |
| total[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[1].category.text | "Submitted Amount" |
| total[1].amount.value | 2650 |
| total[1].amount.currency | #USD |
| total[2].category.coding[0].code | #paidbypatient |
| total[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[2].category.text | "Patient Pay Amount" |
| total[2].amount.value | 0 |
| total[2].amount.currency | #USD |
| item[0].productOrService.coding[0].code | #97110 |
| item[0].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[0].productOrService.coding[0].display | "Physical Therapy" |
| item[0].sequence | 1 |
| item[0].adjudication[0].category.coding[0].code | #submitted |
| item[0].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[0].amount.value | 1000 |
| item[0].adjudication[0].amount.currency | #USD |
| item[0].adjudication[1].category.coding[0].code | #other |
| item[0].adjudication[1].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
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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