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 "EOBProfessionalTransportation1" Updated "2022-09-10 02:46:05-0400"
Information Source: Organization/PayerOrganizationExample1!
Profile: C4BB ExplanationOfBenefit Professional NonClinician (version 2.0.0)
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: ProfessionalTransportationEOBExample1
status: active
type: Professional (Claim Type Codes#professional)
subType: Patient was transported for the benefit of a preferred physician (X12 Ambulance Transport Reason Codes Code System#B)
use: claim
patient: Patient/Patient1 " EXAMPLE1"
billablePeriod: 2022-09-10 --> (ongoing)
created: 2022-09-10 02:46:05-0400
insurer: Organization/Payer2: UPMC Health Plan "UPMC Health Plan"
provider: Organization/ProviderTransportationOrganization1 "ABC Ambulance Services"
| - | Type | Party |
| * | Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider") | Organization/ProviderTransportationOrganization1 "ABC Ambulance Services" |
outcome: complete
| - | Sequence | Provider | Role | Qualification |
| * | 1 | Organization/ProviderTransportationOrganization1 "ABC Ambulance Services" | The rendering care provider. (C4BB Claim Care Team Role Code System#rendering "Rendering provider") | Transportation Services; Non-emergency Medical Transport (VAN) (provider-taxonomy#343900000X) |
supportingInfo
sequence: 1
category: Date the claim was received by the payer. (C4BB Supporting Info Type Code System#clmrecvddate "Claim Received Date")
timing: 2022-09-11
supportingInfo
sequence: 2
category: Patient Weight (C4BB Supporting Info Type Code System#patientweight)
value: 160 [lb_av]
supportingInfo
sequence: 3
category: Ambulance Transport Reason (C4BB Supporting Info Type Code System#ambulancetransportreason)
reason: Patient was transported for the benefit of a preferred physician (Details: https://x12.org/codesystem.x12.org/ambulance-transport-reason-codes code B = 'B', stated as 'Patient was transported for the benefit of a preferred physician')
supportingInfo
sequence: 4
category: Transportation Distance (C4BB Supporting Info Type Code System#transportationdistance)
value: 21 [mi_i]
supportingInfo
sequence: 5
category: Transportation Distance (C4BB Supporting Info Type Code System#transportationdistance)
value: 22 [mi_i]
supportingInfo
sequence: 6
category: Round Trip Purpose (C4BB Supporting Info Type Code System#roudtrippurpose)
value: Trip to facility and then back home
supportingInfo
sequence: 7
category: Stretcher Purpose (C4BB Supporting Info Type Code System#stretcherpurpose)
value: Patient could not walk
supportingInfo
sequence: 8
category: Pick-up Location (C4BB Supporting Info Type Code System#pickuplocation)
value: Patient home; Pittsburgh; PA,15222
supportingInfo
sequence: 9
category: Drop-off Location (C4BB Supporting Info Type Code System#dropofflocation)
value: Orange Medical Group; Pittsburgh; PA,15222
supportingInfo
sequence: 10
category: Pick-up Location (C4BB Supporting Info Type Code System#pickuplocation)
value: Orange Medical Group; Pittsburgh; PA,15222
supportingInfo
sequence: 11
category: Drop-off Location (C4BB Supporting Info Type Code System#dropofflocation)
value: Patient home; Pittsburgh; PA,15222
| - | Sequence | Diagnosis[x] | Type |
| * | 1 | Athscl native arteries of left leg w ulceration of unsp site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I70.249) | The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. (Example Diagnosis Type Codes#principal "Principal Diagnosis") |
| - | Focal | Coverage |
| * | true | Coverage/Coverage1 |
item
sequence: 1
informationSequence: 2, 3, 4, 6, 7, 10, 11
productOrService: Ambulance service, basic life support, non-emergency transport (BLS) (Current Procedural Terminology (CPT®)#A0428)
serviced: 2022-09-10
location: Ambulance - Land (CMS Place of Service Codes (POS)#41)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 40.35 USD adjudication
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 40.35 USD adjudication
category: Amount deducted from the eligible amount prior to adjudication. (Adjudication Value Codes#deductible "Deductible")
Amounts
- Value Currency * 0 USD adjudication
category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")
Amounts
- Value Currency * 40.35 USD
item
sequence: 2
informationSequence: 2, 3, 5, 6, 7, 8, 9
productOrService: Ambulance service, basic life support, non-emergency transport (BLS) (Current Procedural Terminology (CPT®)#A0428)
serviced: 2022-09-10
location: Ambulance - Land (CMS Place of Service Codes (POS)#41)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 42.62 USD adjudication
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 42.62 USD adjudication
category: Amount deducted from the eligible amount prior to adjudication. (Adjudication Value Codes#deductible "Deductible")
Amounts
- Value Currency * 0 USD adjudication
category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")
Amounts
- Value Currency * 42.62 USD
| - | Category | Reason |
| * | Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. (C4BB Adjudication Discriminator Code System#billingnetworkstatus "Billing Network Status") | Indicates the provider was in network for the service (C4BB Payer Adjudication Status Code System#innetwork "In Network") |
total
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 82.97 USD
total
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 82.97 USD
total
category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")
Amounts
- Value Currency * 82.97 USD
total
category: The amount of the member's liability. (C4BB Adjudication Code System#memberliability "Member liability")
Amounts
- Value Currency * 0 USD
Instance: EOBProfessionalTransportation1
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Transportation 1"
Description: "EOB Professional - Transportation 1"
Usage: #example
* meta.lastUpdated = "2022-09-10T14:46:05-04:00"
* meta.source = "Organization/PayerOrganizationExample1"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.0.0"
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc "Unique Claim ID"
* text = "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
* identifier.system = "https://www.example.com/fhir/EOBIdentifier"
* identifier.value = "ProfessionalTransportationEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
* text = "Professional"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2022-09-10"
* created = "2022-09-10T14:46:05-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderTransportationOrganization1)
* payee.type = http://terminology.hl7.org/CodeSystem/payeetype#provider "Provider"
* text = "Any benefit payable will be paid to the provider (Assignment of Benefit)."
* payee.party = Reference(ProviderTransportationOrganization1)
* outcome = #complete
* careTeam.sequence = 1
* careTeam.provider = Reference(ProviderTransportationOrganization1)
* careTeam.role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#rendering "Rendering provider"
* text = "The rendering care provider."
* careTeam.qualification = http://nucc.org/provider-taxonomy#343900000X "Transportation Services; Non-emergency Medical Transport (VAN)"
* supportingInfo[0].sequence = 1
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate "Claim Received Date"
* text = "Date the claim was received by the payer."
* supportingInfo[=].timingDate = "2022-09-11"
* supportingInfo[+].sequence = 2
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientweight
* supportingInfo[=].valueQuantity.value = 160
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[lb_av]"
* supportingInfo[+].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#ambulancetransportreason
* supportingInfo[=].reason = https://x12.org/codesystem.x12.org/5010/1317#B "Patient was transported for the benefit of a preferred physician"
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#transportationdistance
* supportingInfo[=].valueQuantity.value = 21
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[mi_i]"
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#transportationdistance
* supportingInfo[=].valueQuantity.value = 22
* supportingInfo[=].valueQuantity.system = "http://unitsofmeasure.org"
* supportingInfo[=].valueQuantity.unit = "[mi_i]"
* supportingInfo[+].sequence = 6
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#roudtrippurpose
* supportingInfo[=].valueString = "Trip to facility and then back home"
* supportingInfo[+].sequence = 7
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#stretcherpurpose
* supportingInfo[=].valueString = "Patient could not walk"
* supportingInfo[+].sequence = 8
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#pickuplocation
* supportingInfo[=].valueString = "Patient home; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 9
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dropofflocation
* supportingInfo[=].valueString = "Orange Medical Group; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 10
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#pickuplocation
* supportingInfo[=].valueString = "Orange Medical Group; Pittsburgh; PA,15222"
* supportingInfo[+].sequence = 11
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dropofflocation
* supportingInfo[=].valueString = "Patient home; Pittsburgh; PA,15222"
* diagnosis.sequence = 1
* diagnosis.diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I70.249
* diagnosis.type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal "Principal Diagnosis"
* text = "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].informationSequence[0] = 2
* item[=].informationSequence[+] = 3
* item[=].informationSequence[+] = 4
* item[=].informationSequence[+] = 6
* item[=].informationSequence[+] = 7
* item[=].informationSequence[+] = 10
* item[=].informationSequence[+] = 11
* item[=].productOrService = http://www.ama-assn.org/go/cpt#A0428 "Ambulance service, basic life support, non-emergency transport (BLS)"
* item[=].servicedDate = "2022-09-10"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#41
* text = "Ambulance - Land"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 40.35
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* text = "Amount of the change which is considered for adjudication."
* item[=].adjudication[=].amount.value = 40.35
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
* text = "Amount deducted from the eligible amount prior to adjudication."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
* text = "Amount payable under the coverage"
* item[=].adjudication[=].amount.value = 40.35
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 2
* item[=].informationSequence[0] = 2
* item[=].informationSequence[+] = 3
* item[=].informationSequence[+] = 5
* item[=].informationSequence[+] = 6
* item[=].informationSequence[+] = 7
* item[=].informationSequence[+] = 8
* item[=].informationSequence[+] = 9
* item[=].productOrService = http://www.ama-assn.org/go/cpt#A0428 "Ambulance service, basic life support, non-emergency transport (BLS)"
* item[=].servicedDate = "2022-09-10"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#41
* text = "Ambulance - Land"
* 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#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 42.62
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* text = "Amount of the change which is considered for adjudication."
* item[=].adjudication[=].amount.value = 42.62
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
* text = "Amount deducted from the eligible amount prior to adjudication."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
* text = "Amount payable under the coverage"
* item[=].adjudication[=].amount.value = 42.62
* item[=].adjudication[=].amount.currency = #USD
* adjudication.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus "Billing Network Status"
* text = "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
* adjudication.reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork "In Network"
* text = "Indicates the provider was in network for the service"
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* total[=].category.text = "The total submitted amount for the claim or group or line item."
* total[=].amount.value = 82.97
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* text = "Amount of the change which is considered for adjudication."
* total[=].amount.value = 82.97
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
* text = "Amount payable under the coverage"
* total[=].amount.value = 82.97
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#memberliability "Member liability"
* text = "The amount of the member's liability."
* 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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