CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "EOBOutpatient1" Updated "2019-12-12 09:14:11+0000" (Language "en-US")
Profile: C4BB ExplanationOfBenefit Outpatient Institutional (version 2.0.0)
identifier: Unique Claim ID: AW123412341234123412341234123412
status: active
type: Institutional (Claim Type Codes#institutional)
subType: Outpatient (C4BB Institutional Claim SubType Code System#outpatient)
use: claim
patient: Patient/Patient2 " TEST"
billablePeriod: 2019-01-01 --> 2019-10-31
created: 2019-11-02 12:00:00+0000
insurer: Organization/Payer1: Organization Payer 1 "Organization Payer 1"
provider: Organization/ProviderOrganization1: Orange Medical Group "Orange Medical Group"
outcome: partial
| - | Sequence | Provider | Role | Qualification |
| * | 1 | Organization/ProviderOrganization1 "Orange Medical Group" | Rendering provider (C4BB Claim Care Team Role Code System#rendering) | Oncology Clinical Nurse Specialist (provider-taxonomy#364SX0200X) |
supportingInfo
sequence: 2
category: Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)
timing: 2019-11-30
supportingInfo
sequence: 3
category: Type of Bill (C4BB Supporting Info Type Code System#typeofbill)
code: Dummy (AHA NUBC Type Of Bill Codes#Dummy)
supportingInfo
sequence: 4
category: Point Of Origin (C4BB Supporting Info Type Code System#pointoforigin)
code: Dummy (AHA NUBC Point of Origin for Non-newborn#Dummy)
supportingInfo
sequence: 5
category: Admission Type (C4BB Supporting Info Type Code System#admtype)
code: Dummy (AHA NUBC Priority (Type) of Admission or Visit#Dummy)
supportingInfo
sequence: 6
category: Discharge Status (C4BB Supporting Info Type Code System#discharge-status)
code: Dummy (AHA NUBC Patient Discharge Status Codes#Dummy)
supportingInfo
sequence: 7
category: Medical Record Number (C4BB Supporting Info Type Code System#medicalrecordnumber)
value: 1234-234-1243-12345678901m
supportingInfo
sequence: 8
category: Patient Account Number (C4BB Supporting Info Type Code System#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) | Patient Reason for Visit (C4BB Claim Diagnosis Type Code System#patientreasonforvisit) |
| - | Focal | Coverage |
| * | true | Coverage/Coverage3 |
| - | Sequence | Revenue | ProductOrService | Serviced[x] |
| * | 1 | Dummy (AHA NUBC Revenue Codes#Dummy) | Not Applicable (DataAbsentReason#not-applicable) | 2019-11-02 |
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: Payment Amount (C4BB Adjudication Code System#paidtoprovider)
adjudication
category: Patient Pay Amount (C4BB Adjudication Code System#paidbypatient)
total
category: Payment Amount (C4BB Adjudication Code System#paidtoprovider)
Amounts
- Value Currency * 620 USD
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 2650 USD
total
category: Patient Pay Amount (C4BB Adjudication Code System#paidbypatient)
Amounts
- Value Currency * 0 USD
Instance: EOBOutpatient1
InstanceOf: ExplanationOfBenefit
Title: "EOB Outpatient Institutional - Example 1"
Description: "EOB Outpatient Institutional - Example 1"
Usage: #example
* meta.lastUpdated = "2019-12-12T09:14:11+00:00"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0"
* language = #en-US
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc
* identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier"
* identifier.value = "AW123412341234123412341234123412"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
* text = "Institutional"
* subType = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType#outpatient
* text = "Outpatient"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2019-01-01"
* billablePeriod.end = "2019-10-31"
* created = "2019-11-02T00:00:00+00:00"
* insurer = Reference(Payer1) "Organization Payer 1"
* provider = Reference(ProviderOrganization1) "Orange Medical Group"
* outcome = #partial
* careTeam.sequence = 1
* careTeam.provider = Reference(ProviderOrganization1)
* careTeam.role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#rendering "Rendering provider"
* careTeam.qualification = http://nucc.org/provider-taxonomy#364SX0200X "Oncology Clinical Nurse Specialist"
* supportingInfo[0].sequence = 2
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2019-11-30"
* supportingInfo[+].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#typeofbill
* supportingInfo[=].code = https://www.nubc.org/CodeSystem/TypeOfBill#Dummy
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#pointoforigin
* supportingInfo[=].code = https://www.nubc.org/CodeSystem/PointOfOrigin#Dummy
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#admtype
* supportingInfo[=].code = https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit#Dummy
* supportingInfo[+].sequence = 6
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#discharge-status
* supportingInfo[=].code = https://www.nubc.org/CodeSystem/PatDischargeStatus#Dummy
* supportingInfo[+].sequence = 7
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#medicalrecordnumber
* supportingInfo[=].valueString = "1234-234-1243-12345678901m"
* supportingInfo[+].sequence = 8
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientaccountnumber
* supportingInfo[=].valueString = "1234-234-1243-12345678901a"
* diagnosis.sequence = 1
* diagnosis.diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A
* diagnosis.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#patientreasonforvisit
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item.sequence = 1
* item.revenue = https://www.nubc.org/CodeSystem/RevenueCodes#Dummy
* item.productOrService = http://terminology.hl7.org/CodeSystem/data-absent-reason#not-applicable "Not Applicable"
* item.servicedDate = "2019-11-02"
* adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* text = "Payment Amount"
* adjudication[=].amount.value = 620
* adjudication[=].amount.currency = #USD
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidbypatient
* text = "Patient Pay Amount"
* adjudication[=].amount.value = 0
* total[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* total[=].category.text = "Payment Amount"
* total[=].amount.value = 620
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* text = "Submitted Amount"
* total[=].amount.value = 2650
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidbypatient
* text = "Patient Pay Amount"
* total[=].amount.value = 0
* total[=].amount.currency = #USD
IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#2.0.0 based on FHIR 4.0.1. Generated 2022-11-28
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