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="InpatientEOBExample1"/>
<meta>
<lastUpdated value="2020-04-28T15:39:36-04:00"/>
<source value="Organization/PayerOrganizationExample1"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.2.0"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><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 "InpatientEOBExample1" Updated "2020-04-28T19:39:36Z" </p><p style="margin-bottom: 0px">Information Source: Organization/PayerOrganizationExample1!</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional.html">C4BB ExplanationOfBenefit Inpatient Institutional (version 1.2.0)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1</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>: Inpatient <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBInstitutionalClaimSubType.html">C4BB Institutional Claim SubType</a>#inpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-ExamplePatient1.html">Patient/ExamplePatient1</a> " TEST"</p><p><b>billablePeriod</b>: 2017-05-23 --> 2017-05-23</p><p><b>created</b>: 2017-06-01T00:00:00-04:00</p><p><b>insurer</b>: <a href="Organization-PayerOrganizationExample1.html">Organization/PayerOrganizationExample1: UPMC Health Plan</a> "UPMC Health Plan"</p><p><b>provider</b>: <a href="Organization-ProviderOrganization3.html">Organization/ProviderOrganization3</a> "Green Medical Group"</p><h3>Payees</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>Any benefit payable will be paid to the provider (Assignment of Benefit). <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-payeetype.html">ClaimPayeeTypeCodes</a>#provider "Provider")</span></td><td><a href="Organization-ProviderOrganization4.html">Organization/ProviderOrganization4</a> "Blue Medical Group"</td></tr></table><p><b>outcome</b>: complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Practitioner/Practitioner2</a> " BROWN"</p><p><b>role</b>: The attending physician <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimCareTeamRole.html">C4BB Claim Care Team Role</a>#attending "Attending")</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Practitioner/Practitioner2</a> " BROWN"</p><p><b>role</b>: The referring physician <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimCareTeamRole.html">C4BB Claim Care Team Role</a>#referring "Referring")</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#billingnetworkcontractingstatus "Billing Network Contracting Status")</span></p><p><b>code</b>: Indicates the provider was contracted for the service <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#contracted "Contracted")</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Date the claim was received by the payer. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#clmrecvddate "Claim Received Date")</span></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Dates corresponding with the admission and discharge of the beneficiary to a facility <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#admissionperiod "Admission Period")</span></p><p><b>timing</b>: 2017-05-23 --> (ongoing)</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</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><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Non-ST elevation (NSTEMI) myocardial infarction <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>#I21.4)</span></p><p><b>type</b>: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal "Principal Diagnosis")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Athscl heart disease of native cor art w oth ang pctrs <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>#I25.118)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimDiagnosisType.html">C4BB Claim Diagnosis Type</a>#other "Other")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: Hyperlipidemia, unspecified <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>#E78.5)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimDiagnosisType.html">C4BB Claim Diagnosis Type</a>#other "Other")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: Unspecified osteoarthritis, unspecified site <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>#M19.90)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimDiagnosisType.html">C4BB Claim Diagnosis Type</a>#other "Other")</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimProcedureType.html">C4BB Claim Procedure Type</a>#principal "Principal")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: 4A023N7 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-icd10PCS.html">ICD-10 Procedure Codes</a>#4A023N7)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: Other procedures performed during the inpatient institutional admission <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimProcedureType.html">C4BB Claim Procedure Type</a>#other "Other")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: B211YZZ <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-icd10PCS.html">ICD-10 Procedure Codes</a>#B211YZZ)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: Other procedures performed during the inpatient institutional admission <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimProcedureType.html">C4BB Claim Procedure Type</a>#other "Other")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: B215YZZ <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-icd10PCS.html">ICD-10 Procedure Codes</a>#B215YZZ)</span></p></blockquote><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-CoverageEx2.html">Coverage/CoverageEx2</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: 0301 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0301)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: 0260 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0260)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: 0305 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0305)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: 0324 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0324)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: 0259 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0259)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: 0250 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0250)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: 0710 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0710)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: 0210 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0210)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: 0272 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0272)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: 0370 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0370)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: 0730 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0730)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: 0450 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0450)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: 0481 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0481)</span></p><p><b>productOrService</b>: 99231 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#noncovered "Noncovered")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <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 "Submitted Amount")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <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>#eligible "Eligible Amount")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <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>#deductible "Deductible")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Co-Payment <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>#copay "CoPay")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#noncovered "Noncovered")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount payable under the coverage <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>#benefit "Benefit Amount")</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: The amount of the member's liability. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#memberliability "Member liability")</span></p></blockquote></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
<code value="uc"/>
<display value="Unique Claim ID"/>
</coding>
<text
value="Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"/>
</type>
<system value="https://www.upmchealthplan.com/fhir/EOBIdentifier"/>
<value value="InpatientEOBExample1"/>
</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="inpatient"/>
</coding>
<text value="Inpatient"/>
</subType>
<use value="claim"/>
<patient>
<reference value="Patient/ExamplePatient1"/>
</patient>
<billablePeriod>
<start value="2017-05-23"/>
<end value="2017-05-23"/>
</billablePeriod>
<created value="2017-06-01T00:00:00-04:00"/>
<insurer>
<reference value="Organization/PayerOrganizationExample1"/>
<display value="UPMC Health Plan"/>
</insurer>
<provider>
<reference value="Organization/ProviderOrganization3"/>
</provider>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
<display value="Provider"/>
</coding>
<text
value="Any benefit payable will be paid to the provider (Assignment of Benefit)."/>
</type>
<party>
<reference value="Organization/ProviderOrganization4"/>
</party>
</payee>
<outcome value="complete"/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/Practitioner2"/>
</provider>
<role>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
<code value="attending"/>
<display value="Attending"/>
</coding>
<text value="The attending physician"/>
</role>
</careTeam>
<careTeam>
<sequence value="2"/>
<provider>
<reference value="Practitioner/Practitioner2"/>
</provider>
<role>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
<code value="referring"/>
<display value="Referring"/>
</coding>
<text value="The referring physician"/>
</role>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="billingnetworkcontractingstatus"/>
<display value="Billing Network Contracting Status"/>
</coding>
<text
value="Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."/>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
<display value="Contracted"/>
</coding>
<text value="Indicates the provider was contracted for the service"/>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="clmrecvddate"/>
<display value="Claim Received Date"/>
</coding>
<text value="Date the claim was received by the payer."/>
</category>
<timingDate value="2017-06-01"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="admissionperiod"/>
<display value="Admission Period"/>
</coding>
<text
value="Dates corresponding with the admission and discharge of the beneficiary to a facility"/>
</category>
<timingPeriod>
<start value="2017-05-23"/>
</timingPeriod>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<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="I21.4"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
<display value="Principal Diagnosis"/>
</coding>
<text
value="The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."/>
</type>
</diagnosis>
<diagnosis>
<sequence value="2"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="I25.118"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
<code value="other"/>
<display value="Other"/>
</coding>
<text
value="Required when other conditions coexist or develop subsequently during the treatment"/>
</type>
</diagnosis>
<diagnosis>
<sequence value="3"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="E78.5"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
<code value="other"/>
<display value="Other"/>
</coding>
<text
value="Required when other conditions coexist or develop subsequently during the treatment"/>
</type>
</diagnosis>
<diagnosis>
<sequence value="4"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="M19.90"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
<code value="other"/>
<display value="Other"/>
</coding>
<text
value="Required when other conditions coexist or develop subsequently during the treatment"/>
</type>
</diagnosis>
<procedure>
<sequence value="1"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
<code value="principal"/>
<display value="Principal"/>
</coding>
<text
value="The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"/>
</type>
<date value="2017-05-23"/>
<procedureCodeableConcept>
<coding>
<system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
<code value="4A023N7"/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value="2"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
<code value="other"/>
<display value="Other"/>
</coding>
<text
value="Other procedures performed during the inpatient institutional admission"/>
</type>
<date value="2017-05-23"/>
<procedureCodeableConcept>
<coding>
<system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
<code value="B211YZZ"/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value="3"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
<code value="other"/>
<display value="Other"/>
</coding>
<text
value="Other procedures performed during the inpatient institutional admission"/>
</type>
<date value="2017-05-23"/>
<procedureCodeableConcept>
<coding>
<system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
<code value="B215YZZ"/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/CoverageEx2"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0301"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="2"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0260"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="3"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0305"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="4"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0324"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="5"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0259"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="6"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0250"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="7"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0710"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="8"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0210"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="9"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0272"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="10"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0370"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="11"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0730"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="12"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0450"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<item>
<sequence value="13"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0481"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedPeriod>
<start value="2017-05-23"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
</item>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="7147.2"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="1542.01"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="120.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="1393.57"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="memberliability"/>
<display value="Member liability"/>
</coding>
<text value="The amount of the member's liability."/>
</category>
<amount>
<value value="0.0"/>
<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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