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="OutpatientEOBExample1"/>
<meta>
<lastUpdated value="2020-10-13T11:10:24-04:00"/>
<source value="Organization/PayerOrganizationExample1"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-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 "OutpatientEOBExample1" Updated "2020-10-13T15:10:24Z" </p><p style="margin-bottom: 0px">Information Source: Organization/PayerOrganizationExample1!</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>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: OutpatientEOBExample1</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-ExamplePatient1.html">Patient/ExamplePatient1</a> " TEST"</p><p><b>billablePeriod</b>: 2020-09-29 --> 2020-09-29</p><p><b>created</b>: 2020-10-10T00:00:00-04:00</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-ProviderOrganization5.html">Organization/ProviderOrganization5</a> "Black 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-ProviderOrganization6.html">Organization/ProviderOrganization6</a> "White 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-Practitioner1.html">Practitioner/Practitioner1</a> " SMITH"</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-Practitioner3.html">Practitioner/Practitioner3</a> " WILLIAMS"</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>: 2020-10-10</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Out Of Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#outofnetwork)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Orthostatic hypotension <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>#I95.1)</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>: Orthostatic hypotension <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>#I95.1)</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>: Non-pressure chronic ulcer oth prt left foot w unsp severity <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>#L97.529)</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>: Peripheral vascular disease, 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>#I73.9)</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><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-CoverageEx1.html">Coverage/CoverageEx1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: 0551 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0551)</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>: 2020-09-29</p><p><b>location</b>: HOME <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#12)</span></p><blockquote><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: 0023 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-AHANUBCRevenueCodes.html">NUBC Revenue Codes</a>#0023)</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>: 2020-09-29</p><p><b>location</b>: HOME <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#12)</span></p><blockquote><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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><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="OutpatientEOBExample1"/>
</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/ExamplePatient1"/>
</patient>
<billablePeriod>
<start value="2020-09-29"/>
<end value="2020-09-29"/>
</billablePeriod>
<created value="2020-10-10T00:00:00-04:00"/>
<insurer>
<reference value="Organization/PayerOrganizationExample1"/>
<display value="UPMC Health Plan"/>
</insurer>
<provider>
<reference value="Organization/ProviderOrganization5"/>
</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/ProviderOrganization6"/>
</party>
</payee>
<outcome value="complete"/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/Practitioner1"/>
</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/Practitioner3"/>
</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="2020-10-10"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="outofnetwork"/>
</coding>
</category>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="I95.1"/>
</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="I95.1"/>
</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="L97.529"/>
</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="I73.9"/>
</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>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/CoverageEx1"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0551"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedDate value="2020-09-29"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="12"/>
</coding>
<text value="HOME"/>
</locationCodeableConcept>
<adjudication>
<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="84.4"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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="56.52"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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>
</adjudication>
<adjudication>
<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="56.52"/>
<currency value="USD"/>
</amount>
</adjudication>
<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>
</item>
<item>
<sequence value="2"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0023"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="99231"/>
</coding>
</productOrService>
<servicedDate value="2020-09-29"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="12"/>
</coding>
<text value="HOME"/>
</locationCodeableConcept>
<adjudication>
<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="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<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>
</adjudication>
<adjudication>
<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="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<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>
</item>
<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="84.4"/>
<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="56.52"/>
<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="0.0"/>
<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="56.52"/>
<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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