CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.1.0 - STU1 Update
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.1.0 - STU1 Update
This page is part of the CARIN Blue Button Implementation Guide (v1.1.0: STU 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 
{
"resourceType" : "ExplanationOfBenefit",
"id" : "InpatientEOBExample1",
"meta" : {
"lastUpdated" : "2020-04-28T15:39:36-04:00",
"source" : "Organization/PayerOrganizationExample1",
"profile" : [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|1.1.0"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>subType</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType inpatient}\">Inpatient</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-ExamplePatient1.html\">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}\">unknown</span></a></p><p><b>billablePeriod</b>: 2017-05-23 --> 2017-05-23</p><p><b>created</b>: Jun 1, 2017 4:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization-PayerOrganizationExample1.html\">UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}\">Payer</span>; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization3.html\">Generated Summary: National Provider Identifier: 3334445550; active; name: Green Medical Group</a></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><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/payeetype provider}\">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href=\"Organization-ProviderOrganization4.html\">Generated Summary: National Provider Identifier: 4445556660; active; name: Blue Medical Group</a></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-Practitioner2.html\">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole attending}\">The attending physician</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole referring}\">The referring physician</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType billingnetworkcontractingstatus}\">Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.</span></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus contracted}\">Indicates the provider was contracted for the service</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Date the claim was received by the payer.</span></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}\">Dates corresponding with the admission and discharge of the beneficiary to a facility</span></p><p><b>timing</b>: 2017-05-23 --> (ongoing)</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm I21.4}\">Non-ST elevation (NSTEMI) myocardial infarction</span></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm I25.118}\">Athscl heart disease of native cor art w oth ang pctrs</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm E78.5}\">Hyperlipidemia, unspecified</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm M19.90}\">Unspecified osteoarthritis, unspecified site</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType principal}\">The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 4A023N7}\">4A023N7</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B211YZZ}\">B211YZZ</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B215YZZ}\">B215YZZ</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-CoverageEx2.html\">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status: active; subscriberId: 888009335; dependent: 01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span>; period: 2017-01-01 --> 2017-06-30; network: GI8-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0301}\">0301</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0260}\">0260</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0305}\">0305</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0324}\">0324</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0259}\">0259</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0250}\">0250</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0710}\">0710</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0210}\">0210</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0272}\">0272</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0370}\">0370</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0730}\">0730</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0450}\">0450</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: <span title=\"Codes: {https://www.nubc.org/CodeSystem/RevenueCodes 0481}\">0481</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}\">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></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}\">The total submitted amount for the claim or group or line item.</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Amount of the change which is considered for adjudication.</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}\">Amount deducted from the eligible amount prior to adjudication.</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}\">Patient Co-Payment</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}\">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></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Amount payable under the coverage</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication memberliability}\">The amount of the member's liability.</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc",
"display" : "Unique Claim ID"
}
],
"text" : "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
},
"system" : "https://www.upmchealthplan.com/fhir/EOBIdentifier",
"value" : "InpatientEOBExample1"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
],
"text" : "Institutional"
},
"subType" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
"code" : "inpatient"
}
],
"text" : "Inpatient"
},
"use" : "claim",
"patient" : {
"reference" : "Patient/ExamplePatient1"
},
"billablePeriod" : {
"start" : "2017-05-23",
"end" : "2017-05-23"
},
"created" : "2017-06-01T00:00:00-04:00",
"insurer" : {
"reference" : "Organization/PayerOrganizationExample1",
"display" : "UPMC Health Plan"
},
"provider" : {
"reference" : "Organization/ProviderOrganization3"
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider",
"display" : "Provider"
}
],
"text" : "Any benefit payable will be paid to the provider (Assignment of Benefit)."
},
"party" : {
"reference" : "Organization/ProviderOrganization4"
}
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/Practitioner2"
},
"role" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code" : "attending",
"display" : "Attending"
}
],
"text" : "The attending physician"
}
},
{
"sequence" : 2,
"provider" : {
"reference" : "Practitioner/Practitioner2"
},
"role" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code" : "referring",
"display" : "Referring"
}
],
"text" : "The referring physician"
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "billingnetworkcontractingstatus",
"display" : "Billing Network Contracting Status"
}
],
"text" : "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "contracted",
"display" : "Contracted"
}
],
"text" : "Indicates the provider was contracted for the service"
}
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate",
"display" : "Claim Received Date"
}
],
"text" : "Date the claim was received by the payer."
},
"timingDate" : "2017-06-01"
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admissionperiod",
"display" : "Admission Period"
}
],
"text" : "Dates corresponding with the admission and discharge of the beneficiary to a facility"
},
"timingPeriod" : {
"start" : "2017-05-23"
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "I21.4"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal",
"display" : "Principal Diagnosis"
}
],
"text" : "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
}
]
},
{
"sequence" : 2,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "I25.118"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence" : 3,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "E78.5"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence" : 4,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "M19.90"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Required when other conditions coexist or develop subsequently during the treatment"
}
]
}
],
"procedure" : [
{
"sequence" : 1,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "principal",
"display" : "Principal"
}
],
"text" : "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "4A023N7"
}
]
}
},
{
"sequence" : 2,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Other procedures performed during the inpatient institutional admission"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "B211YZZ"
}
]
}
},
{
"sequence" : 3,
"type" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code" : "other",
"display" : "Other"
}
],
"text" : "Other procedures performed during the inpatient institutional admission"
}
],
"date" : "2017-05-23",
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/ICD10",
"code" : "B215YZZ"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/CoverageEx2"
}
}
],
"item" : [
{
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0301"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 2,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0260"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 3,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0305"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 4,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0324"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 5,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0259"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 6,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0250"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 7,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0710"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 8,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0210"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 9,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0272"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 10,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0370"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 11,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0730"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 12,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0450"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence" : 13,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0481"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"servicedPeriod" : {
"start" : "2017-05-23"
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
],
"text" : "HOSPITAL - INPATIENT HOSPITAL"
}
}
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "noncovered",
"display" : "Noncovered"
}
],
"text" : "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."
},
"amount" : {
"value" : 0.0,
"currency" : "USD"
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
],
"text" : "The total submitted amount for the claim or group or line item."
},
"amount" : {
"value" : 7147.2,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible",
"display" : "Eligible Amount"
}
],
"text" : "Amount of the change which is considered for adjudication."
},
"amount" : {
"value" : 1542.01,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "deductible",
"display" : "Deductible"
}
],
"text" : "Amount deducted from the eligible amount prior to adjudication."
},
"amount" : {
"value" : 0.0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay",
"display" : "CoPay"
}
],
"text" : "Patient Co-Payment"
},
"amount" : {
"value" : 120.0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "noncovered",
"display" : "Noncovered"
}
],
"text" : "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."
},
"amount" : {
"value" : 0.0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit",
"display" : "Benefit Amount"
}
],
"text" : "Amount payable under the coverage"
},
"amount" : {
"value" : 1393.57,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "memberliability",
"display" : "Member liability"
}
],
"text" : "The amount of the member's liability."
},
"amount" : {
"value" : 0.0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
},
"amount" : {
"value" : 0.0,
"currency" : "USD"
}
}
]
}
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.1.0 based on FHIR 4.0.1. Generated 2021-07-02
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