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 
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "InpatientEOBExample1"];
fhir:Resource.meta [
fhir:Meta.lastUpdated [ fhir:value "2020-04-28T15:39:36-04:00"^^xsd:dateTime ];
fhir:Meta.source [ fhir:value "Organization/PayerOrganizationExample1" ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional> ]
];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-ExamplePatient1.html\">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}\">unknown</span></a></p><p><b>billablePeriod</b>: 2017-05-23 --> 2017-05-23</p><p><b>created</b>: Jun 1, 2017 4:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization-PayerOrganizationExample1.html\">UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}\">Payer</span>; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization3.html\">Generated Summary: National Provider Identifier: 3334445550; active; name: Green Medical Group</a></p><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/payeetype provider}\">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href=\"Organization-ProviderOrganization4.html\">Generated Summary: National Provider Identifier: 4445556660; active; name: Blue Medical Group</a></td></tr></table><p><b>outcome</b>: complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole attending}\">The attending physician</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole referring}\">The referring physician</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType billingnetworkcontractingstatus}\">Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.</span></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus contracted}\">Indicates the provider was contracted for the service</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Date the claim was received by the payer.</span></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}\">Dates corresponding with the admission and discharge of the beneficiary to a facility</span></p><p><b>timing</b>: 2017-05-23 --> (ongoing)</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm I21.4}\">I21.4</span></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm I25.118}\">I25.118</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm E78.5}\">E78.5</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10-cm M19.90}\">M19.90</span></p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}\">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType principal}\">The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 4A023N7}\">4A023N7</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B211YZZ}\">B211YZZ</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}\">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title=\"Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B215YZZ}\">B215YZZ</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-CoverageEx2.html\">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status: active; subscriberId: 888009335; dependent: 01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span>; period: 2017-01-01 --> 2017-06-30; network: GI8-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0301}\">0301</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0260}\">0260</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0305}\">0305</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0324}\">0324</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0259}\">0259</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0250}\">0250</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0710}\">0710</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0210}\">0210</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0272}\">0272</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0370}\">0370</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0730}\">0730</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0450}\">0450</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: <span title=\"Codes: {http://www.nubc.org/RevenueCodes 0481}\">0481</span></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99231}\">99231</span></p><p><b>serviced</b>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: <span title=\"Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></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><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>"
];
fhir:ExplanationOfBenefit.identifier [
fhir:index 0;
fhir:Identifier.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" ];
fhir:Coding.code [ fhir:value "uc" ];
fhir:Coding.display [ fhir:value "Unique Claim ID" ] ];
fhir:CodeableConcept.text [ fhir:value "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" ] ];
fhir:Identifier.system [ fhir:value "https://www.upmchealthplan.com/fhir/EOBIdentifier" ];
fhir:Identifier.value [ fhir:value "InpatientEOBExample1" ]
];
fhir:ExplanationOfBenefit.status [ fhir:value "active"];
fhir:ExplanationOfBenefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
fhir:Coding.code [ fhir:value "institutional" ] ];
fhir:CodeableConcept.text [ fhir:value "Institutional" ]
];
fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
fhir:ExplanationOfBenefit.patient [
fhir:Reference.reference [ fhir:value "Patient/ExamplePatient1" ]
];
fhir:ExplanationOfBenefit.billablePeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ];
fhir:Period.end [ fhir:value "2017-05-23"^^xsd:date ]
];
fhir:ExplanationOfBenefit.created [ fhir:value "2017-06-01T00:00:00-04:00"^^xsd:dateTime];
fhir:ExplanationOfBenefit.insurer [
fhir:Reference.reference [ fhir:value "Organization/PayerOrganizationExample1" ];
fhir:Reference.display [ fhir:value "UPMC Health Plan" ]
];
fhir:ExplanationOfBenefit.provider [
fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization3" ]
];
fhir:ExplanationOfBenefit.payee [
fhir:ExplanationOfBenefit.payee.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
fhir:Coding.code [ fhir:value "provider" ];
fhir:Coding.display [ fhir:value "Provider" ] ];
fhir:CodeableConcept.text [ fhir:value "Any benefit payable will be paid to the provider (Assignment of Benefit)." ] ];
fhir:ExplanationOfBenefit.payee.party [
fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization4" ] ]
];
fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
fhir:ExplanationOfBenefit.careTeam [
fhir:index 0;
fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.careTeam.provider [
fhir:Reference.reference [ fhir:value "Practitioner/Practitioner2" ] ];
fhir:ExplanationOfBenefit.careTeam.role [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" ];
fhir:Coding.code [ fhir:value "attending" ];
fhir:Coding.display [ fhir:value "Attending" ] ];
fhir:CodeableConcept.text [ fhir:value "The attending physician" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.careTeam.provider [
fhir:Reference.reference [ fhir:value "Practitioner/Practitioner2" ] ];
fhir:ExplanationOfBenefit.careTeam.role [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" ];
fhir:Coding.code [ fhir:value "referring" ];
fhir:Coding.display [ fhir:value "Referring" ] ];
fhir:CodeableConcept.text [ fhir:value "The referring physician" ] ]
];
fhir:ExplanationOfBenefit.supportingInfo [
fhir:index 0;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "billingnetworkcontractingstatus" ];
fhir:Coding.display [ fhir:value "Billing Network Contracting Status" ] ];
fhir:CodeableConcept.text [ fhir:value "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." ] ];
fhir:ExplanationOfBenefit.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
fhir:Coding.code [ fhir:value "contracted" ];
fhir:Coding.display [ fhir:value "Contracted" ] ];
fhir:CodeableConcept.text [ fhir:value "Indicates the provider was contracted for the service" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "clmrecvddate" ];
fhir:Coding.display [ fhir:value "Claim Received Date" ] ];
fhir:CodeableConcept.text [ fhir:value "Date the claim was received by the payer." ] ];
fhir:ExplanationOfBenefit.supportingInfo.timingDate [ fhir:value "2017-06-01"^^xsd:date ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "admissionperiod" ];
fhir:Coding.display [ fhir:value "Admission Period" ] ];
fhir:CodeableConcept.text [ fhir:value "Dates corresponding with the admission and discharge of the beneficiary to a facility" ] ];
fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ]
];
fhir:ExplanationOfBenefit.diagnosis [
fhir:index 0;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "I21.4" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" ];
fhir:Coding.code [ fhir:value "principal" ];
fhir:Coding.display [ fhir:value "Principal Diagnosis" ] ];
fhir:CodeableConcept.text [ fhir:value "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "I25.118" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "E78.5" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "4"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "M19.90" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
];
fhir:ExplanationOfBenefit.procedure [
fhir:index 0;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "principal" ];
fhir:Coding.display [ fhir:value "Principal" ] ];
fhir:CodeableConcept.text [ fhir:value "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "4A023N7" ] ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Other procedures performed during the inpatient institutional admission" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "B211YZZ" ] ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Other procedures performed during the inpatient institutional admission" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "B215YZZ" ] ] ]
];
fhir:ExplanationOfBenefit.insurance [
fhir:index 0;
fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
fhir:ExplanationOfBenefit.insurance.coverage [
fhir:Reference.reference [ fhir:value "Coverage/CoverageEx2" ] ]
];
fhir:ExplanationOfBenefit.item [
fhir:index 0;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0301" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "386.5"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0260" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "322.4"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0305" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "104.2"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "4"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0324" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "171.6"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "5"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0259" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "381.8"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "6"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0250" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "54.2"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 6;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "7"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0710" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "642.8"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 7;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "8"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0210" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "1258.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "120.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "1542.01"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "1393.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 8;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "9"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0272" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "303.4"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 9;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "10"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0370" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "222.8"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 10;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "11"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0730" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "33.9"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 11;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "12"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0450" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "592.4"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 12;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "13"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.nubc.org/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0481" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "2673.2"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
];
fhir:ExplanationOfBenefit.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
];
fhir:ExplanationOfBenefit.total [
fhir:index 0;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "7147.2"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "1542.01"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "120.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 4;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir: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." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 5;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "1393.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 6;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "memberliability" ];
fhir:Coding.display [ fhir:value "Member liability" ] ];
fhir:CodeableConcept.text [ fhir:value "The amount of the member's liability." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0.0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.
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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