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 
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "EOBPharmacy1"];
fhir:Resource.meta [
fhir:Meta.lastUpdated [ fhir:value "2019-12-12T09:14:11+00:00"^^xsd:dateTime ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0> ]
];
fhir:Resource.language [ fhir:value "en-US"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBPharmacy1\"> </a></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 ExplanationOfBenefit "EOBPharmacy1" Updated "2019-12-12 09:14:11+0000" (Language "en-US") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Pharmacy.html\">C4BB ExplanationOfBenefit Pharmacy (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient2.html\">Patient/Patient2</a> " TEST"</p><p><b>billablePeriod</b>: 2019-10-30 --> 2019-10-31</p><p><b>created</b>: 2019-07-02 12:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">Organization/Payer1: XXX Health Plan</a> "Organization Payer 1"</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1: XXX Health Plan</a> "Orange Medical Group"</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Days Supply <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#dayssupply)</span></p><p><b>value</b>: 30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: DAW (Dispense As Written) Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#dawcode)</span></p><p><b>code</b>: 7 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPDispensedAsWrittenOrProductSelectionCode.html\">NCPDP Dispense As Written (DAW)/Product Selection Code</a>#7)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Refill Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#refillnum)</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Refills Authorized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#refillsauthorized)</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Brand Generic Indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#brandgenericindicator)</span></p><p><b>code</b>: 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPBrandGenericIndicator.html\">NCPDP Brand Generic Indicator</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Rx Origin Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#rxorigincode)</span></p><p><b>code</b>: 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPPrescriptionOriginCode.html\">NCPDP Prescription Origin Code</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</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 Code System</a>#clmrecvddate)</span></p><p><b>timing</b>: 2019-10-31</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: Compound Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#compoundcode)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPCompoundCode.html\">NCPDP Compound Code</a>#Dummy)</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-Coverage3.html\">Coverage/Coverage3</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-v3-ndc.html\">National drug codes</a>#0777-3105-02)</span></p><p><b>serviced</b>: 2019-07-02</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1000</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#discount)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>900</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Member liability <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#memberliability)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>80</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Paid to provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td>Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr><tr><td>*</td><td>Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr></table><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 Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>620</td><td>USD</td></tr></table></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/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>2650</td><td>USD</td></tr></table></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 Code System</a>#paidbypatient)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
];
fhir:ExplanationOfBenefit.identifier [
fhir:index 0;
fhir:Identifier.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" ];
fhir:Coding.code [ fhir:value "uc" ] ] ];
fhir:Identifier.system [ fhir:value "https://www.xxxplan.com/fhir/EOBIdentifier" ];
fhir:Identifier.value [ fhir:value "AW123412341234123412341234123412" ]
];
fhir:ExplanationOfBenefit.status [ fhir:value "active"];
fhir:ExplanationOfBenefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
fhir:Coding.code [ fhir:value "pharmacy" ] ];
fhir:CodeableConcept.text [ fhir:value "Pharmacy" ]
];
fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
fhir:ExplanationOfBenefit.patient [
fhir:Reference.reference [ fhir:value "Patient/Patient2" ]
];
fhir:ExplanationOfBenefit.billablePeriod [
fhir:Period.start [ fhir:value "2019-10-30"^^xsd:date ];
fhir:Period.end [ fhir:value "2019-10-31"^^xsd:date ]
];
fhir:ExplanationOfBenefit.created [ fhir:value "2019-07-02T00:00:00+00:00"^^xsd:dateTime];
fhir:ExplanationOfBenefit.insurer [
fhir:Reference.reference [ fhir:value "Organization/Payer1" ];
fhir:Reference.display [ fhir:value "XXX Health Plan" ]
];
fhir:ExplanationOfBenefit.provider [
fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization1" ];
fhir:Reference.display [ fhir:value "XXX Health Plan" ]
];
fhir:ExplanationOfBenefit.outcome [ fhir:value "partial"];
fhir:ExplanationOfBenefit.supportingInfo [
fhir:index 0;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "8"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "dayssupply" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [
fhir:Quantity.value [ fhir:value "30"^^xsd:decimal ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "6"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "dawcode" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode" ];
fhir:Coding.code [ fhir:value "7" ] ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "4"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "refillnum" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "5"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "refillsauthorized" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.valueQuantity [
fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ]
], [
fhir:index 4;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "brandgenericindicator" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator" ];
fhir:Coding.code [ fhir:value "2" ] ] ]
], [
fhir:index 5;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "rxorigincode" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode" ];
fhir:Coding.code [ fhir:value "1" ] ] ]
], [
fhir:index 6;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "7"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "clmrecvddate" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.timingDate [ fhir:value "2019-10-31"^^xsd:date ]
], [
fhir:index 7;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "9"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "compoundcode" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode" ];
fhir:Coding.code [ fhir:value "Dummy" ] ] ]
];
fhir:ExplanationOfBenefit.insurance [
fhir:index 0;
fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
fhir:ExplanationOfBenefit.insurance.coverage [
fhir:Reference.reference [ fhir:value "Coverage/Coverage3" ] ]
];
fhir:ExplanationOfBenefit.item [
fhir:index 0;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/ndc" ];
fhir:Coding.code [ fhir:value "0777-3105-02" ];
fhir:Coding.display [ fhir:value "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)" ] ] ];
fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2019-07-02"^^xsd:date ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "1000"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "20"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "discount" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "900"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "memberliability" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "80"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "paidtoprovider" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "20"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
];
fhir:ExplanationOfBenefit.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
fhir:Coding.code [ fhir:value "benefitpaymentstatus" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.reason [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
fhir:Coding.code [ fhir:value "innetwork" ] ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
fhir:Coding.code [ fhir:value "billingnetworkstatus" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.reason [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
fhir:Coding.code [ fhir:value "innetwork" ] ] ]
];
fhir:ExplanationOfBenefit.total [
fhir:index 0;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "paidtoprovider" ] ];
fhir:CodeableConcept.text [ fhir:value "Payment Amount" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "620"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ] ];
fhir:CodeableConcept.text [ fhir:value "Submitted Amount" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "2650"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "paidbypatient" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Pay Amount" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.
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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