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 
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="ProfessionalEOBExample1"/>
<meta>
<lastUpdated value="2020-10-20T14:46:05-04:00"/>
<source value="Organization/PayerOrganizationExample1"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.1.0"/>
</meta>
<text>
<status value="generated"/>
<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: ProfessionalEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</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>: 2020-08-04 --> 2020-08-04</p><p><b>created</b>: Aug 24, 2020 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-ProviderOrganization1.html">Generated Summary: National Provider Identifier: 1112223330; active; name: Orange 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-ProviderOrganization1.html">Generated Summary: National Provider Identifier: 1112223330; active; name: Orange 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="Organization-ProviderOrganization1.html">Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group</a></p><p><b>role</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claimcareteamrole primary}">The primary care provider.</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-Practitioner1.html">Generated Summary: National Provider Identifier: 6667778880; active; John Smith </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>: 2020-08-24</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 I70.249}">Athscl native arteries of left leg w ulceration of unsp site</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 L97.929}">Non-prs chronic ulc unsp prt of l low leg w unsp severity</span></p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType secondary}">Required when necessary to report additional diagnoses on professional and non-clinician claims</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-CoverageEx1.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: 2020-01-01 --> (ongoing); network: GR5-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 75710}">75710</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 75710}">75710</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 75710}">75710</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 37228}">37228</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 37228}">37228</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 37228}">37228</span></p><p><b>serviced</b>: 2020-08-04</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><p><b>adjudication</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>adjudication</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>adjudication</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>adjudication</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>adjudication</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>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>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider</span></p></blockquote></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></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
<code value="uc"/>
<display value="Unique Claim ID"/>
</coding>
<text
value="Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"/>
</type>
<system value="https://www.upmchealthplan.com/fhir/EOBIdentifier"/>
<value value="ProfessionalEOBExample1"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
<text value="Professional"/>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/ExamplePatient1"/>
</patient>
<billablePeriod>
<start value="2020-08-04"/>
<end value="2020-08-04"/>
</billablePeriod>
<created value="2020-08-24T00:00:00-04:00"/>
<insurer>
<reference value="Organization/PayerOrganizationExample1"/>
<display value="UPMC Health Plan"/>
</insurer>
<provider>
<reference value="Organization/ProviderOrganization1"/>
</provider>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
<display value="Provider"/>
</coding>
<text
value="Any benefit payable will be paid to the provider (Assignment of Benefit)."/>
</type>
<party>
<reference value="Organization/ProviderOrganization1"/>
</party>
</payee>
<outcome value="complete"/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Organization/ProviderOrganization1"/>
</provider>
<role>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claimcareteamrole"/>
<code value="primary"/>
<display value="Primary provider"/>
</coding>
<text value="The primary care provider."/>
</role>
</careTeam>
<careTeam>
<sequence value="2"/>
<provider>
<reference value="Practitioner/Practitioner1"/>
</provider>
<role>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
<code value="referring"/>
<display value="Referring"/>
</coding>
<text value="The referring physician"/>
</role>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="billingnetworkcontractingstatus"/>
<display value="Billing Network Contracting Status"/>
</coding>
<text
value="Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."/>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
<display value="Contracted"/>
</coding>
<text value="Indicates the provider was contracted for the service"/>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="clmrecvddate"/>
<display value="Claim Received Date"/>
</coding>
<text value="Date the claim was received by the payer."/>
</category>
<timingDate value="2020-08-24"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="I70.249"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
<display value="Principal Diagnosis"/>
</coding>
<text
value="The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."/>
</type>
</diagnosis>
<diagnosis>
<sequence value="2"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="L97.929"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
<code value="secondary"/>
<display value="secondary"/>
</coding>
<text
value="Required when necessary to report additional diagnoses on professional and non-clinician claims"/>
</type>
</diagnosis>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/CoverageEx1"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="75710"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="68.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<item>
<sequence value="2"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="75710"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="-68.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="-34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="-34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<item>
<sequence value="3"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="75710"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="68.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="34.8"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<item>
<sequence value="4"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="37228"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="751.2"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<item>
<sequence value="5"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="37228"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="751.2"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<item>
<sequence value="6"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="37228"/>
</coding>
</productOrService>
<servicedDate value="2020-08-04"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
<text value="HOSPITAL - INPATIENT HOSPITAL"/>
</locationCodeableConcept>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="-751.2"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="-224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="-224.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
<display value="In Network"/>
</coding>
<text
value="Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider"/>
</category>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
<text
value="The total submitted amount for the claim or group or line item."/>
</category>
<amount>
<value value="820.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
<display value="Eligible Amount"/>
</coding>
<text value="Amount of the change which is considered for adjudication."/>
</category>
<amount>
<value value="258.91"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text
value="Amount deducted from the eligible amount prior to adjudication."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
<display value="CoPay"/>
</coding>
<text value="Patient Co-Payment"/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="noncovered"/>
<display value="Noncovered"/>
</coding>
<text
value="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."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
<display value="Benefit Amount"/>
</coding>
<text value="Amount payable under the coverage"/>
</category>
<amount>
<value value="258.91"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="memberliability"/>
<display value="Member liability"/>
</coding>
<text value="The amount of the member's liability."/>
</category>
<amount>
<value value="0.0"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>
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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