CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1
This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: 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 
Generated Narrative
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1
status: active
type: Institutional
use: claim
billablePeriod: 2017-05-23 --> 2017-05-23
created: Jun 1, 2017 4:00:00 AM
provider: Generated Summary: National Provider Identifier: 3334445550; active; name: Green Medical Group
| - | Type | Party |
| * | Any benefit payable will be paid to the provider (Assignment of Benefit). | Generated Summary: National Provider Identifier: 4445556660; active; name: Blue Medical Group |
outcome: complete
careTeam
sequence: 1
provider: Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown
role: The attending physician
careTeam
sequence: 2
provider: Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown
role: The referring physician
supportingInfo
sequence: 1
category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.
code: Indicates the provider was contracted for the service
supportingInfo
sequence: 2
category: Date the claim was received by the payer.
timing: 2017-06-01
supportingInfo
sequence: 3
category: Dates corresponding with the admission and discharge of the beneficiary to a facility
timing: 2017-05-23 --> (ongoing)
diagnosis
sequence: 1
diagnosis: I21.4
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.
diagnosis
sequence: 2
diagnosis: I25.118
type: Required when other conditions coexist or develop subsequently during the treatment
diagnosis
sequence: 3
diagnosis: E78.5
type: Required when other conditions coexist or develop subsequently during the treatment
diagnosis
sequence: 4
diagnosis: M19.90
type: Required when other conditions coexist or develop subsequently during the treatment
procedure
sequence: 1
type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis
date: 2017-05-23
procedure: 4A023N7
procedure
sequence: 2
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: B211YZZ
procedure
sequence: 3
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: B215YZZ
item
sequence: 1
revenue: 0301
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 2
revenue: 0260
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 3
revenue: 0305
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 4
revenue: 0324
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 5
revenue: 0259
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 6
revenue: 0250
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 7
revenue: 0710
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 8
revenue: 0210
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 9
revenue: 0272
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 10
revenue: 0370
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 11
revenue: 0730
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 12
revenue: 0450
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
item
sequence: 13
revenue: 0481
productOrService: 99231
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: 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.
Amounts
- *
adjudication
category: 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.
Amounts
- *
total
category: The total submitted amount for the claim or group or line item.
Amounts
- *
total
category: Amount of the change which is considered for adjudication.
Amounts
- *
total
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- *
total
category: Patient Co-Payment
Amounts
- *
total
category: 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.
Amounts
- *
total
category: Amount payable under the coverage
Amounts
- *
total
category: The amount of the member's liability.
Amounts
- *
| Field | Value |
| resourceType | "ExplanationOfBenefit" |
| id | "InpatientEOBExample1" |
| meta.lastUpdated | "2020-04-28T15:39:36-04:00" |
| meta.source | "Organization/PayerOrganizationExample1" |
| meta.profile[0] | "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional" |
| identifier[0].type.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" |
| identifier[0].type.coding[0].code | #uc |
| identifier[0].type.coding[0].display | "Unique Claim ID" |
| identifier[0].type.text | "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" |
| identifier[0].system | "https://www.upmchealthplan.com/fhir/EOBIdentifier" |
| identifier[0].value | InpatientEOBExample1 |
| status | "active" |
| type.coding[0].system | "http://terminology.hl7.org/CodeSystem/claim-type" |
| type.coding[0].code | #institutional |
| type.text | "Institutional" |
| use | "claim" |
| patient.reference | "Patient/ExamplePatient1" |
| billablePeriod.start | "2017-05-23" |
| billablePeriod.end | "2017-05-23" |
| created | "2017-06-01T00:00:00-04:00" |
| insurer.reference | "Organization/PayerOrganizationExample1" |
| insurer.display | "UPMC Health Plan" |
| provider.reference | "Organization/ProviderOrganization3" |
| payee.type.coding[0].system | "http://terminology.hl7.org/CodeSystem/payeetype" |
| payee.type.coding[0].code | #provider |
| payee.type.coding[0].display | "Provider" |
| payee.type.text | "Any benefit payable will be paid to the provider (Assignment of Benefit)." |
| payee.party.reference | "Organization/ProviderOrganization4" |
| outcome | "complete" |
| careTeam[0].sequence | 1 |
| careTeam[0].provider.reference | "Practitioner/Practitioner2" |
| careTeam[0].role.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" |
| careTeam[0].role.coding[0].code | #attending |
| careTeam[0].role.coding[0].display | "Attending" |
| careTeam[0].role.text | "The attending physician" |
| careTeam[1].sequence | 2 |
| careTeam[1].provider.reference | "Practitioner/Practitioner2" |
| careTeam[1].role.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" |
| careTeam[1].role.coding[0].code | #referring |
| careTeam[1].role.coding[0].display | "Referring" |
| careTeam[1].role.text | "The referring physician" |
| supportingInfo[0].sequence | 1 |
| supportingInfo[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[0].category.coding[0].code | #billingnetworkcontractingstatus |
| supportingInfo[0].category.coding[0].display | "Billing Network Contracting Status" |
| supportingInfo[0].category.text | "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." |
| supportingInfo[0].code.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| supportingInfo[0].code.coding[0].code | #contracted |
| supportingInfo[0].code.coding[0].display | "Contracted" |
| supportingInfo[0].code.text | "Indicates the provider was contracted for the service" |
| supportingInfo[1].sequence | 2 |
| supportingInfo[1].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[1].category.coding[0].code | #clmrecvddate |
| supportingInfo[1].category.coding[0].display | "Claim Received Date" |
| supportingInfo[1].category.text | "Date the claim was received by the payer." |
| supportingInfo[1].timingDate | "2017-06-01" |
| supportingInfo[2].sequence | 3 |
| supportingInfo[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[2].category.coding[0].code | #admissionperiod |
| supportingInfo[2].category.coding[0].display | "Admission Period" |
| supportingInfo[2].category.text | "Dates corresponding with the admission and discharge of the beneficiary to a facility" |
| supportingInfo[2].timingPeriod.start | "2017-05-23" |
| diagnosis[0].sequence | 1 |
| diagnosis[0].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[0].diagnosisCodeableConcept.coding[0].code | #I21.4 |
| diagnosis[0].type[0].coding[0].system | "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" |
| diagnosis[0].type[0].coding[0].code | #principal |
| diagnosis[0].type[0].coding[0].display | "Principal Diagnosis" |
| diagnosis[0].type[0].text | "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." |
| diagnosis[1].sequence | 2 |
| diagnosis[1].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[1].diagnosisCodeableConcept.coding[0].code | #I25.118 |
| diagnosis[1].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" |
| diagnosis[1].type[0].coding[0].code | #other |
| diagnosis[1].type[0].coding[0].display | "Other" |
| diagnosis[1].type[0].text | "Required when other conditions coexist or develop subsequently during the treatment" |
| diagnosis[2].sequence | 3 |
| diagnosis[2].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[2].diagnosisCodeableConcept.coding[0].code | #E78.5 |
| diagnosis[2].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" |
| diagnosis[2].type[0].coding[0].code | #other |
| diagnosis[2].type[0].coding[0].display | "Other" |
| diagnosis[2].type[0].text | "Required when other conditions coexist or develop subsequently during the treatment" |
| diagnosis[3].sequence | 4 |
| diagnosis[3].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[3].diagnosisCodeableConcept.coding[0].code | #M19.90 |
| diagnosis[3].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" |
| diagnosis[3].type[0].coding[0].code | #other |
| diagnosis[3].type[0].coding[0].display | "Other" |
| diagnosis[3].type[0].text | "Required when other conditions coexist or develop subsequently during the treatment" |
| procedure[0].sequence | 1 |
| procedure[0].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" |
| procedure[0].type[0].coding[0].code | #principal |
| procedure[0].type[0].coding[0].display | "Principal" |
| procedure[0].type[0].text | "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis" |
| procedure[0].date | "2017-05-23" |
| procedure[0].procedureCodeableConcept.coding[0].system | "http://www.cms.gov/Medicare/Coding/ICD10" |
| procedure[0].procedureCodeableConcept.coding[0].code | #4A023N7 |
| procedure[1].sequence | 2 |
| procedure[1].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" |
| procedure[1].type[0].coding[0].code | #other |
| procedure[1].type[0].coding[0].display | "Other" |
| procedure[1].type[0].text | "Other procedures performed during the inpatient institutional admission" |
| procedure[1].date | "2017-05-23" |
| procedure[1].procedureCodeableConcept.coding[0].system | "http://www.cms.gov/Medicare/Coding/ICD10" |
| procedure[1].procedureCodeableConcept.coding[0].code | #B211YZZ |
| procedure[2].sequence | 3 |
| procedure[2].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" |
| procedure[2].type[0].coding[0].code | #other |
| procedure[2].type[0].coding[0].display | "Other" |
| procedure[2].type[0].text | "Other procedures performed during the inpatient institutional admission" |
| procedure[2].date | "2017-05-23" |
| procedure[2].procedureCodeableConcept.coding[0].system | "http://www.cms.gov/Medicare/Coding/ICD10" |
| procedure[2].procedureCodeableConcept.coding[0].code | #B215YZZ |
| insurance[0].focal | "true" |
| insurance[0].coverage.reference | "Coverage/CoverageEx2" |
| item[0].sequence | 1 |
| item[0].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[0].revenue.coding[0].code | #0301 |
| item[0].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[0].productOrService.coding[0].code | #99231 |
| item[0].servicedPeriod.start | "2017-05-23" |
| item[0].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[0].locationCodeableConcept.coding[0].code | #21 |
| item[0].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[0].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[0].category.coding[0].code | #submitted |
| item[0].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[0].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[0].adjudication[0].amount.value | 386.5 |
| item[0].adjudication[0].amount.currency | #USD |
| item[0].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[1].category.coding[0].code | #copay |
| item[0].adjudication[1].category.coding[0].display | "CoPay" |
| item[0].adjudication[1].category.text | "Patient Co-Payment" |
| item[0].adjudication[1].amount.value | 0.0 |
| item[0].adjudication[1].amount.currency | #USD |
| item[0].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[2].category.coding[0].code | #eligible |
| item[0].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[0].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[0].adjudication[2].amount.value | 0.0 |
| item[0].adjudication[2].amount.currency | #USD |
| item[0].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[3].category.coding[0].code | #deductible |
| item[0].adjudication[3].category.coding[0].display | "Deductible" |
| item[0].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[0].adjudication[3].amount.value | 0.0 |
| item[0].adjudication[3].amount.currency | #USD |
| item[0].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[4].category.coding[0].code | #benefit |
| item[0].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[0].adjudication[4].category.text | "Amount payable under the coverage" |
| item[0].adjudication[4].amount.value | 0.0 |
| item[0].adjudication[4].amount.currency | #USD |
| item[0].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[0].adjudication[5].category.coding[0].code | #noncovered |
| item[0].adjudication[5].category.coding[0].display | "Noncovered" |
| item[0].adjudication[5].category.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." |
| item[0].adjudication[5].amount.value | 0.0 |
| item[0].adjudication[5].amount.currency | #USD |
| item[1].sequence | 2 |
| item[1].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[1].revenue.coding[0].code | #0260 |
| item[1].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[1].productOrService.coding[0].code | #99231 |
| item[1].servicedPeriod.start | "2017-05-23" |
| item[1].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[1].locationCodeableConcept.coding[0].code | #21 |
| item[1].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[1].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[0].category.coding[0].code | #submitted |
| item[1].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[1].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[1].adjudication[0].amount.value | 322.4 |
| item[1].adjudication[0].amount.currency | #USD |
| item[1].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[1].category.coding[0].code | #copay |
| item[1].adjudication[1].category.coding[0].display | "CoPay" |
| item[1].adjudication[1].category.text | "Patient Co-Payment" |
| item[1].adjudication[1].amount.value | 0.0 |
| item[1].adjudication[1].amount.currency | #USD |
| item[1].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[2].category.coding[0].code | #eligible |
| item[1].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[1].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[1].adjudication[2].amount.value | 0.0 |
| item[1].adjudication[2].amount.currency | #USD |
| item[1].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[3].category.coding[0].code | #deductible |
| item[1].adjudication[3].category.coding[0].display | "Deductible" |
| item[1].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[1].adjudication[3].amount.value | 0.0 |
| item[1].adjudication[3].amount.currency | #USD |
| item[1].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[4].category.coding[0].code | #benefit |
| item[1].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[1].adjudication[4].category.text | "Amount payable under the coverage" |
| item[1].adjudication[4].amount.value | 0.0 |
| item[1].adjudication[4].amount.currency | #USD |
| item[1].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[1].adjudication[5].category.coding[0].code | #noncovered |
| item[1].adjudication[5].category.coding[0].display | "Noncovered" |
| item[1].adjudication[5].category.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." |
| item[1].adjudication[5].amount.value | 0.0 |
| item[1].adjudication[5].amount.currency | #USD |
| item[2].sequence | 3 |
| item[2].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[2].revenue.coding[0].code | #0305 |
| item[2].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[2].productOrService.coding[0].code | #99231 |
| item[2].servicedPeriod.start | "2017-05-23" |
| item[2].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[2].locationCodeableConcept.coding[0].code | #21 |
| item[2].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[2].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[0].category.coding[0].code | #submitted |
| item[2].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[2].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[2].adjudication[0].amount.value | 104.2 |
| item[2].adjudication[0].amount.currency | #USD |
| item[2].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[1].category.coding[0].code | #copay |
| item[2].adjudication[1].category.coding[0].display | "CoPay" |
| item[2].adjudication[1].category.text | "Patient Co-Payment" |
| item[2].adjudication[1].amount.value | 0.0 |
| item[2].adjudication[1].amount.currency | #USD |
| item[2].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[2].category.coding[0].code | #eligible |
| item[2].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[2].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[2].adjudication[2].amount.value | 0.0 |
| item[2].adjudication[2].amount.currency | #USD |
| item[2].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[3].category.coding[0].code | #deductible |
| item[2].adjudication[3].category.coding[0].display | "Deductible" |
| item[2].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[2].adjudication[3].amount.value | 0.0 |
| item[2].adjudication[3].amount.currency | #USD |
| item[2].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[4].category.coding[0].code | #benefit |
| item[2].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[2].adjudication[4].category.text | "Amount payable under the coverage" |
| item[2].adjudication[4].amount.value | 0.0 |
| item[2].adjudication[4].amount.currency | #USD |
| item[2].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[2].adjudication[5].category.coding[0].code | #noncovered |
| item[2].adjudication[5].category.coding[0].display | "Noncovered" |
| item[2].adjudication[5].category.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." |
| item[2].adjudication[5].amount.value | 0.0 |
| item[2].adjudication[5].amount.currency | #USD |
| item[3].sequence | 4 |
| item[3].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[3].revenue.coding[0].code | #0324 |
| item[3].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[3].productOrService.coding[0].code | #99231 |
| item[3].servicedPeriod.start | "2017-05-23" |
| item[3].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[3].locationCodeableConcept.coding[0].code | #21 |
| item[3].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[3].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[0].category.coding[0].code | #submitted |
| item[3].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[3].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[3].adjudication[0].amount.value | 171.6 |
| item[3].adjudication[0].amount.currency | #USD |
| item[3].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[1].category.coding[0].code | #copay |
| item[3].adjudication[1].category.coding[0].display | "CoPay" |
| item[3].adjudication[1].category.text | "Patient Co-Payment" |
| item[3].adjudication[1].amount.value | 0.0 |
| item[3].adjudication[1].amount.currency | #USD |
| item[3].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[2].category.coding[0].code | #eligible |
| item[3].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[3].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[3].adjudication[2].amount.value | 0.0 |
| item[3].adjudication[2].amount.currency | #USD |
| item[3].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[3].category.coding[0].code | #deductible |
| item[3].adjudication[3].category.coding[0].display | "Deductible" |
| item[3].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[3].adjudication[3].amount.value | 0.0 |
| item[3].adjudication[3].amount.currency | #USD |
| item[3].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[4].category.coding[0].code | #benefit |
| item[3].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[3].adjudication[4].category.text | "Amount payable under the coverage" |
| item[3].adjudication[4].amount.value | 0.0 |
| item[3].adjudication[4].amount.currency | #USD |
| item[3].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[3].adjudication[5].category.coding[0].code | #noncovered |
| item[3].adjudication[5].category.coding[0].display | "Noncovered" |
| item[3].adjudication[5].category.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." |
| item[3].adjudication[5].amount.value | 0.0 |
| item[3].adjudication[5].amount.currency | #USD |
| item[4].sequence | 5 |
| item[4].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[4].revenue.coding[0].code | #0259 |
| item[4].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[4].productOrService.coding[0].code | #99231 |
| item[4].servicedPeriod.start | "2017-05-23" |
| item[4].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[4].locationCodeableConcept.coding[0].code | #21 |
| item[4].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[4].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[0].category.coding[0].code | #submitted |
| item[4].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[4].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[4].adjudication[0].amount.value | 381.8 |
| item[4].adjudication[0].amount.currency | #USD |
| item[4].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[1].category.coding[0].code | #copay |
| item[4].adjudication[1].category.coding[0].display | "CoPay" |
| item[4].adjudication[1].category.text | "Patient Co-Payment" |
| item[4].adjudication[1].amount.value | 0.0 |
| item[4].adjudication[1].amount.currency | #USD |
| item[4].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[2].category.coding[0].code | #eligible |
| item[4].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[4].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[4].adjudication[2].amount.value | 0.0 |
| item[4].adjudication[2].amount.currency | #USD |
| item[4].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[3].category.coding[0].code | #deductible |
| item[4].adjudication[3].category.coding[0].display | "Deductible" |
| item[4].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[4].adjudication[3].amount.value | 0.0 |
| item[4].adjudication[3].amount.currency | #USD |
| item[4].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[4].category.coding[0].code | #benefit |
| item[4].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[4].adjudication[4].category.text | "Amount payable under the coverage" |
| item[4].adjudication[4].amount.value | 0.0 |
| item[4].adjudication[4].amount.currency | #USD |
| item[4].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[4].adjudication[5].category.coding[0].code | #noncovered |
| item[4].adjudication[5].category.coding[0].display | "Noncovered" |
| item[4].adjudication[5].category.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." |
| item[4].adjudication[5].amount.value | 0.0 |
| item[4].adjudication[5].amount.currency | #USD |
| item[5].sequence | 6 |
| item[5].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[5].revenue.coding[0].code | #0250 |
| item[5].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[5].productOrService.coding[0].code | #99231 |
| item[5].servicedPeriod.start | "2017-05-23" |
| item[5].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[5].locationCodeableConcept.coding[0].code | #21 |
| item[5].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[5].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[0].category.coding[0].code | #submitted |
| item[5].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[5].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[5].adjudication[0].amount.value | 54.2 |
| item[5].adjudication[0].amount.currency | #USD |
| item[5].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[1].category.coding[0].code | #copay |
| item[5].adjudication[1].category.coding[0].display | "CoPay" |
| item[5].adjudication[1].category.text | "Patient Co-Payment" |
| item[5].adjudication[1].amount.value | 0.0 |
| item[5].adjudication[1].amount.currency | #USD |
| item[5].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[2].category.coding[0].code | #eligible |
| item[5].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[5].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[5].adjudication[2].amount.value | 0.0 |
| item[5].adjudication[2].amount.currency | #USD |
| item[5].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[3].category.coding[0].code | #deductible |
| item[5].adjudication[3].category.coding[0].display | "Deductible" |
| item[5].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[5].adjudication[3].amount.value | 0.0 |
| item[5].adjudication[3].amount.currency | #USD |
| item[5].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[4].category.coding[0].code | #benefit |
| item[5].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[5].adjudication[4].category.text | "Amount payable under the coverage" |
| item[5].adjudication[4].amount.value | 0.0 |
| item[5].adjudication[4].amount.currency | #USD |
| item[5].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[5].adjudication[5].category.coding[0].code | #noncovered |
| item[5].adjudication[5].category.coding[0].display | "Noncovered" |
| item[5].adjudication[5].category.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." |
| item[5].adjudication[5].amount.value | 0.0 |
| item[5].adjudication[5].amount.currency | #USD |
| item[6].sequence | 7 |
| item[6].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[6].revenue.coding[0].code | #0710 |
| item[6].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[6].productOrService.coding[0].code | #99231 |
| item[6].servicedPeriod.start | "2017-05-23" |
| item[6].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[6].locationCodeableConcept.coding[0].code | #21 |
| item[6].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[6].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[6].adjudication[0].category.coding[0].code | #submitted |
| item[6].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[6].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[6].adjudication[0].amount.value | 642.8 |
| item[6].adjudication[0].amount.currency | #USD |
| item[6].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[6].adjudication[1].category.coding[0].code | #copay |
| item[6].adjudication[1].category.coding[0].display | "CoPay" |
| item[6].adjudication[1].category.text | "Patient Co-Payment" |
| item[6].adjudication[1].amount.value | 0.0 |
| item[6].adjudication[1].amount.currency | #USD |
| item[6].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[6].adjudication[2].category.coding[0].code | #eligible |
| item[6].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[6].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[6].adjudication[2].amount.value | 0.0 |
| item[6].adjudication[2].amount.currency | #USD |
| item[6].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[6].adjudication[3].category.coding[0].code | #deductible |
| item[6].adjudication[3].category.coding[0].display | "Deductible" |
| item[6].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[6].adjudication[3].amount.value | 0.0 |
| item[6].adjudication[3].amount.currency | #USD |
| item[6].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[6].adjudication[4].category.coding[0].code | #benefit |
| item[6].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[6].adjudication[4].category.text | "Amount payable under the coverage" |
| item[6].adjudication[4].amount.value | 0.0 |
| item[6].adjudication[4].amount.currency | #USD |
| item[6].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[6].adjudication[5].category.coding[0].code | #noncovered |
| item[6].adjudication[5].category.coding[0].display | "Noncovered" |
| item[6].adjudication[5].category.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." |
| item[6].adjudication[5].amount.value | 0.0 |
| item[6].adjudication[5].amount.currency | #USD |
| item[7].sequence | 8 |
| item[7].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[7].revenue.coding[0].code | #0210 |
| item[7].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[7].productOrService.coding[0].code | #99231 |
| item[7].servicedPeriod.start | "2017-05-23" |
| item[7].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[7].locationCodeableConcept.coding[0].code | #21 |
| item[7].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[7].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[7].adjudication[0].category.coding[0].code | #submitted |
| item[7].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[7].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[7].adjudication[0].amount.value | 1258.0 |
| item[7].adjudication[0].amount.currency | #USD |
| item[7].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[7].adjudication[1].category.coding[0].code | #copay |
| item[7].adjudication[1].category.coding[0].display | "CoPay" |
| item[7].adjudication[1].category.text | "Patient Co-Payment" |
| item[7].adjudication[1].amount.value | 120.0 |
| item[7].adjudication[1].amount.currency | #USD |
| item[7].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[7].adjudication[2].category.coding[0].code | #eligible |
| item[7].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[7].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[7].adjudication[2].amount.value | 1542.01 |
| item[7].adjudication[2].amount.currency | #USD |
| item[7].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[7].adjudication[3].category.coding[0].code | #deductible |
| item[7].adjudication[3].category.coding[0].display | "Deductible" |
| item[7].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[7].adjudication[3].amount.value | 0.0 |
| item[7].adjudication[3].amount.currency | #USD |
| item[7].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[7].adjudication[4].category.coding[0].code | #benefit |
| item[7].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[7].adjudication[4].category.text | "Amount payable under the coverage" |
| item[7].adjudication[4].amount.value | 1393.57 |
| item[7].adjudication[4].amount.currency | #USD |
| item[7].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[7].adjudication[5].category.coding[0].code | #noncovered |
| item[7].adjudication[5].category.coding[0].display | "Noncovered" |
| item[7].adjudication[5].category.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." |
| item[7].adjudication[5].amount.value | 0.0 |
| item[7].adjudication[5].amount.currency | #USD |
| item[8].sequence | 9 |
| item[8].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[8].revenue.coding[0].code | #0272 |
| item[8].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[8].productOrService.coding[0].code | #99231 |
| item[8].servicedPeriod.start | "2017-05-23" |
| item[8].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[8].locationCodeableConcept.coding[0].code | #21 |
| item[8].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[8].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[8].adjudication[0].category.coding[0].code | #submitted |
| item[8].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[8].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[8].adjudication[0].amount.value | 303.4 |
| item[8].adjudication[0].amount.currency | #USD |
| item[8].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[8].adjudication[1].category.coding[0].code | #copay |
| item[8].adjudication[1].category.coding[0].display | "CoPay" |
| item[8].adjudication[1].category.text | "Patient Co-Payment" |
| item[8].adjudication[1].amount.value | 0.0 |
| item[8].adjudication[1].amount.currency | #USD |
| item[8].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[8].adjudication[2].category.coding[0].code | #eligible |
| item[8].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[8].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[8].adjudication[2].amount.value | 0.0 |
| item[8].adjudication[2].amount.currency | #USD |
| item[8].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[8].adjudication[3].category.coding[0].code | #deductible |
| item[8].adjudication[3].category.coding[0].display | "Deductible" |
| item[8].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[8].adjudication[3].amount.value | 0.0 |
| item[8].adjudication[3].amount.currency | #USD |
| item[8].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[8].adjudication[4].category.coding[0].code | #benefit |
| item[8].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[8].adjudication[4].category.text | "Amount payable under the coverage" |
| item[8].adjudication[4].amount.value | 0.0 |
| item[8].adjudication[4].amount.currency | #USD |
| item[8].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[8].adjudication[5].category.coding[0].code | #noncovered |
| item[8].adjudication[5].category.coding[0].display | "Noncovered" |
| item[8].adjudication[5].category.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." |
| item[8].adjudication[5].amount.value | 0.0 |
| item[8].adjudication[5].amount.currency | #USD |
| item[9].sequence | 10 |
| item[9].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[9].revenue.coding[0].code | #0370 |
| item[9].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[9].productOrService.coding[0].code | #99231 |
| item[9].servicedPeriod.start | "2017-05-23" |
| item[9].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[9].locationCodeableConcept.coding[0].code | #21 |
| item[9].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[9].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[9].adjudication[0].category.coding[0].code | #submitted |
| item[9].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[9].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[9].adjudication[0].amount.value | 222.8 |
| item[9].adjudication[0].amount.currency | #USD |
| item[9].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[9].adjudication[1].category.coding[0].code | #copay |
| item[9].adjudication[1].category.coding[0].display | "CoPay" |
| item[9].adjudication[1].category.text | "Patient Co-Payment" |
| item[9].adjudication[1].amount.value | 0.0 |
| item[9].adjudication[1].amount.currency | #USD |
| item[9].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[9].adjudication[2].category.coding[0].code | #eligible |
| item[9].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[9].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[9].adjudication[2].amount.value | 0.0 |
| item[9].adjudication[2].amount.currency | #USD |
| item[9].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[9].adjudication[3].category.coding[0].code | #deductible |
| item[9].adjudication[3].category.coding[0].display | "Deductible" |
| item[9].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[9].adjudication[3].amount.value | 0.0 |
| item[9].adjudication[3].amount.currency | #USD |
| item[9].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[9].adjudication[4].category.coding[0].code | #benefit |
| item[9].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[9].adjudication[4].category.text | "Amount payable under the coverage" |
| item[9].adjudication[4].amount.value | 0.0 |
| item[9].adjudication[4].amount.currency | #USD |
| item[9].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[9].adjudication[5].category.coding[0].code | #noncovered |
| item[9].adjudication[5].category.coding[0].display | "Noncovered" |
| item[9].adjudication[5].category.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." |
| item[9].adjudication[5].amount.value | 0.0 |
| item[9].adjudication[5].amount.currency | #USD |
| item[10].sequence | 11 |
| item[10].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[10].revenue.coding[0].code | #0730 |
| item[10].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[10].productOrService.coding[0].code | #99231 |
| item[10].servicedPeriod.start | "2017-05-23" |
| item[10].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[10].locationCodeableConcept.coding[0].code | #21 |
| item[10].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[10].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[10].adjudication[0].category.coding[0].code | #submitted |
| item[10].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[10].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[10].adjudication[0].amount.value | 33.9 |
| item[10].adjudication[0].amount.currency | #USD |
| item[10].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[10].adjudication[1].category.coding[0].code | #copay |
| item[10].adjudication[1].category.coding[0].display | "CoPay" |
| item[10].adjudication[1].category.text | "Patient Co-Payment" |
| item[10].adjudication[1].amount.value | 0.0 |
| item[10].adjudication[1].amount.currency | #USD |
| item[10].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[10].adjudication[2].category.coding[0].code | #eligible |
| item[10].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[10].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[10].adjudication[2].amount.value | 0.0 |
| item[10].adjudication[2].amount.currency | #USD |
| item[10].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[10].adjudication[3].category.coding[0].code | #deductible |
| item[10].adjudication[3].category.coding[0].display | "Deductible" |
| item[10].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[10].adjudication[3].amount.value | 0.0 |
| item[10].adjudication[3].amount.currency | #USD |
| item[10].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[10].adjudication[4].category.coding[0].code | #benefit |
| item[10].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[10].adjudication[4].category.text | "Amount payable under the coverage" |
| item[10].adjudication[4].amount.value | 0.0 |
| item[10].adjudication[4].amount.currency | #USD |
| item[10].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[10].adjudication[5].category.coding[0].code | #noncovered |
| item[10].adjudication[5].category.coding[0].display | "Noncovered" |
| item[10].adjudication[5].category.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." |
| item[10].adjudication[5].amount.value | 0.0 |
| item[10].adjudication[5].amount.currency | #USD |
| item[11].sequence | 12 |
| item[11].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[11].revenue.coding[0].code | #0450 |
| item[11].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[11].productOrService.coding[0].code | #99231 |
| item[11].servicedPeriod.start | "2017-05-23" |
| item[11].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[11].locationCodeableConcept.coding[0].code | #21 |
| item[11].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[11].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[11].adjudication[0].category.coding[0].code | #submitted |
| item[11].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[11].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[11].adjudication[0].amount.value | 592.4 |
| item[11].adjudication[0].amount.currency | #USD |
| item[11].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[11].adjudication[1].category.coding[0].code | #copay |
| item[11].adjudication[1].category.coding[0].display | "CoPay" |
| item[11].adjudication[1].category.text | "Patient Co-Payment" |
| item[11].adjudication[1].amount.value | 0.0 |
| item[11].adjudication[1].amount.currency | #USD |
| item[11].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[11].adjudication[2].category.coding[0].code | #eligible |
| item[11].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[11].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[11].adjudication[2].amount.value | 0.0 |
| item[11].adjudication[2].amount.currency | #USD |
| item[11].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[11].adjudication[3].category.coding[0].code | #deductible |
| item[11].adjudication[3].category.coding[0].display | "Deductible" |
| item[11].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[11].adjudication[3].amount.value | 0.0 |
| item[11].adjudication[3].amount.currency | #USD |
| item[11].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[11].adjudication[4].category.coding[0].code | #benefit |
| item[11].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[11].adjudication[4].category.text | "Amount payable under the coverage" |
| item[11].adjudication[4].amount.value | 0.0 |
| item[11].adjudication[4].amount.currency | #USD |
| item[11].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[11].adjudication[5].category.coding[0].code | #noncovered |
| item[11].adjudication[5].category.coding[0].display | "Noncovered" |
| item[11].adjudication[5].category.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." |
| item[11].adjudication[5].amount.value | 0.0 |
| item[11].adjudication[5].amount.currency | #USD |
| item[12].sequence | 13 |
| item[12].revenue.coding[0].system | "http://www.nubc.org/RevenueCodes" |
| item[12].revenue.coding[0].code | #0481 |
| item[12].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[12].productOrService.coding[0].code | #99231 |
| item[12].servicedPeriod.start | "2017-05-23" |
| item[12].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[12].locationCodeableConcept.coding[0].code | #21 |
| item[12].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[12].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[12].adjudication[0].category.coding[0].code | #submitted |
| item[12].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[12].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[12].adjudication[0].amount.value | 2673.2 |
| item[12].adjudication[0].amount.currency | #USD |
| item[12].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[12].adjudication[1].category.coding[0].code | #copay |
| item[12].adjudication[1].category.coding[0].display | "CoPay" |
| item[12].adjudication[1].category.text | "Patient Co-Payment" |
| item[12].adjudication[1].amount.value | 0.0 |
| item[12].adjudication[1].amount.currency | #USD |
| item[12].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[12].adjudication[2].category.coding[0].code | #eligible |
| item[12].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[12].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[12].adjudication[2].amount.value | 0.0 |
| item[12].adjudication[2].amount.currency | #USD |
| item[12].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[12].adjudication[3].category.coding[0].code | #deductible |
| item[12].adjudication[3].category.coding[0].display | "Deductible" |
| item[12].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[12].adjudication[3].amount.value | 0.0 |
| item[12].adjudication[3].amount.currency | #USD |
| item[12].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[12].adjudication[4].category.coding[0].code | #benefit |
| item[12].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[12].adjudication[4].category.text | "Amount payable under the coverage" |
| item[12].adjudication[4].amount.value | 0.0 |
| item[12].adjudication[4].amount.currency | #USD |
| item[12].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[12].adjudication[5].category.coding[0].code | #noncovered |
| item[12].adjudication[5].category.coding[0].display | "Noncovered" |
| item[12].adjudication[5].category.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." |
| item[12].adjudication[5].amount.value | 0.0 |
| item[12].adjudication[5].amount.currency | #USD |
| adjudication[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| adjudication[0].category.coding[0].code | #noncovered |
| adjudication[0].category.coding[0].display | "Noncovered" |
| adjudication[0].category.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." |
| adjudication[0].amount.value | 0.0 |
| adjudication[0].amount.currency | #USD |
| total[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[0].category.coding[0].code | #submitted |
| total[0].category.coding[0].display | "Submitted Amount" |
| total[0].category.text | "The total submitted amount for the claim or group or line item." |
| total[0].amount.value | 7147.2 |
| total[0].amount.currency | #USD |
| total[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[1].category.coding[0].code | #eligible |
| total[1].category.coding[0].display | "Eligible Amount" |
| total[1].category.text | "Amount of the change which is considered for adjudication." |
| total[1].amount.value | 1542.01 |
| total[1].amount.currency | #USD |
| total[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[2].category.coding[0].code | #deductible |
| total[2].category.coding[0].display | "Deductible" |
| total[2].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| total[2].amount.value | 0.0 |
| total[2].amount.currency | #USD |
| total[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[3].category.coding[0].code | #copay |
| total[3].category.coding[0].display | "CoPay" |
| total[3].category.text | "Patient Co-Payment" |
| total[3].amount.value | 120.0 |
| total[3].amount.currency | #USD |
| total[4].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[4].category.coding[0].code | #noncovered |
| total[4].category.coding[0].display | "Noncovered" |
| total[4].category.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." |
| total[4].amount.value | 0.0 |
| total[4].amount.currency | #USD |
| total[5].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[5].category.coding[0].code | #benefit |
| total[5].category.coding[0].display | "Benefit Amount" |
| total[5].category.text | "Amount payable under the coverage" |
| total[5].amount.value | 1393.57 |
| total[5].amount.currency | #USD |
| total[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[6].category.coding[0].code | #memberliability |
| total[6].category.coding[0].display | "Member liability" |
| total[6].category.text | "The amount of the member's liability." |
| total[6].amount.value | 0.0 |
| total[6].amount.currency | #USD |
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.0.0 based on FHIR 4.0.1. Generated 2020-11-23
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