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 "EOBProfessional1" Updated "2019-12-12 09:14:11+0000" (Language "en-US")
Profile: C4BB ExplanationOfBenefit Professional NonClinician (version 2.0.0)
identifier: Unique Claim ID: AW123412341234123412341234123413
status: active
type: Professional (Claim Type Codes#professional)
use: claim
patient: Patient/Patient2 " TEST"
billablePeriod: 2019-01-01 --> 2019-10-31
created: 2019-07-02 12:00:00+0000
insurer: Organization/Payer1: XXX Health Plan "Organization Payer 1"
provider: Organization/ProviderOrganization1: XXX Health Plan "Orange Medical Group"
outcome: partial
supportingInfo
sequence: 3
category: Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)
timing: 2011-05-30
supportingInfo
sequence: 4
category: Service Facility (C4BB Supporting Info Type Code System#servicefacility)
value: Organization/ProviderOrganization1 "Orange Medical Group"
supportingInfo
sequence: 5
category: Medical Record Number (C4BB Supporting Info Type Code System#medicalrecordnumber)
value: 1234-234-1243-12345678901m
supportingInfo
sequence: 6
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) | Principal Diagnosis (Example Diagnosis Type Codes#principal) |
| - | Focal | Coverage |
| * | true | Coverage/Coverage3 |
item
sequence: 1
productOrService: Physical Therapy (Current Procedural Terminology (CPT®)#97110)
serviced: 2019-07-02
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: Other (C4BB Payer Adjudication Status Code System#other)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 1000 USD
| - | Category | Reason |
| * | Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
| * | Rendering Network Status (C4BB Adjudication Discriminator Code System#renderingnetworkstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
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: EOBProfessional1
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Example 1"
Description: "EOB Professional - 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-Professional-NonClinician|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 = "AW123412341234123412341234123413"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
* text = "Professional"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2019-01-01"
* billablePeriod.end = "2019-10-31"
* created = "2019-07-02T00:00:00+00:00"
* insurer = Reference(Payer1) "XXX Health Plan"
* provider = Reference(ProviderOrganization1) "XXX Health Plan"
* outcome = #partial
* supportingInfo[0].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2011-05-30"
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#servicefacility
* supportingInfo[=].valueReference = Reference(ProviderOrganization1)
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#medicalrecordnumber
* supportingInfo[=].valueString = "1234-234-1243-12345678901m"
* supportingInfo[+].sequence = 6
* 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://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item.sequence = 1
* item.productOrService = http://www.ama-assn.org/go/cpt#97110 "Physical Therapy"
* item.servicedDate = "2019-07-02"
* item.locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* item.adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item.adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#other
* item.adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* item.adjudication[=].amount.value = 1000
* item.adjudication[=].amount.currency = #USD
* adjudication[0].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/C4BBAdjudicationDiscriminator#renderingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* 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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