CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1
This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions 
Generated Narrative
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: ProfessionalEOBExample1
status: active
type: Professional
use: claim
billablePeriod: 2020-08-04 --> 2020-08-04
created: Aug 24, 2020 4:00:00 AM
provider: Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group
| - | Type | Party |
| * | Any benefit payable will be paid to the provider (Assignment of Benefit). | Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group |
outcome: complete
careTeam
sequence: 1
provider: Generated Summary: National Provider Identifier: 1112223330; active; name: Orange Medical Group
role: The primary care provider.
careTeam
sequence: 2
provider: Generated Summary: National Provider Identifier: 6667778880; active; John Smith
role: The referring physician
supportingInfo
sequence: 1
category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.
code: Indicates the provider was contracted for the service
supportingInfo
sequence: 2
category: Date the claim was received by the payer.
timing: 2020-08-24
diagnosis
sequence: 1
diagnosis: I70.249
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.
diagnosis
sequence: 2
diagnosis: L97.929
type: Required when necessary to report additional diagnoses on professional and non-clinician claims
item
sequence: 1
productOrService: 75710
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
item
sequence: 2
productOrService: 75710
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
item
sequence: 3
productOrService: 75710
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
item
sequence: 4
productOrService: 37228
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
item
sequence: 5
productOrService: 37228
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
item
sequence: 6
productOrService: 37228
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
- * adjudication
category: Patient Co-Payment
Amounts
- * adjudication
category: Amount of the change which is considered for adjudication.
Amounts
- * adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- * adjudication
category: Amount payable under the coverage
Amounts
- * adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- * adjudication
category: Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
total
category: The total submitted amount for the claim or group or line item.
Amounts
- *
total
category: Amount of the change which is considered for adjudication.
Amounts
- *
total
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
- *
total
category: Patient Co-Payment
Amounts
- *
total
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
Amounts
- *
total
category: Amount payable under the coverage
Amounts
- *
total
category: The amount of the member's liability.
Amounts
- *
| Field | Value |
| resourceType | "ExplanationOfBenefit" |
| id | "ProfessionalEOBExample1" |
| meta.lastUpdated | "2020-10-20T14:46:05-04:00" |
| meta.source | "Organization/PayerOrganizationExample1" |
| meta.profile[0] | "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" |
| identifier[0].type.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" |
| identifier[0].type.coding[0].code | #uc |
| identifier[0].type.coding[0].display | "Unique Claim ID" |
| identifier[0].type.text | "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" |
| identifier[0].system | "https://www.upmchealthplan.com/fhir/EOBIdentifier" |
| identifier[0].value | ProfessionalEOBExample1 |
| status | "active" |
| type.coding[0].system | "http://terminology.hl7.org/CodeSystem/claim-type" |
| type.coding[0].code | #professional |
| type.text | "Professional" |
| use | "claim" |
| patient.reference | "Patient/ExamplePatient1" |
| billablePeriod.start | "2020-08-04" |
| billablePeriod.end | "2020-08-04" |
| created | "2020-08-24T00:00:00-04:00" |
| insurer.reference | "Organization/PayerOrganizationExample1" |
| insurer.display | "UPMC Health Plan" |
| provider.reference | "Organization/ProviderOrganization1" |
| payee.type.coding[0].system | "http://terminology.hl7.org/CodeSystem/payeetype" |
| payee.type.coding[0].code | #provider |
| payee.type.coding[0].display | "Provider" |
| payee.type.text | "Any benefit payable will be paid to the provider (Assignment of Benefit)." |
| payee.party.reference | "Organization/ProviderOrganization1" |
| outcome | "complete" |
| careTeam[0].sequence | 1 |
| careTeam[0].provider.reference | "Organization/ProviderOrganization1" |
| careTeam[0].role.coding[0].system | "http://terminology.hl7.org/CodeSystem/claimcareteamrole" |
| careTeam[0].role.coding[0].code | #primary |
| careTeam[0].role.coding[0].display | "Primary provider" |
| careTeam[0].role.text | "The primary care provider." |
| careTeam[1].sequence | 2 |
| careTeam[1].provider.reference | "Practitioner/Practitioner1" |
| careTeam[1].role.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" |
| careTeam[1].role.coding[0].code | #referring |
| careTeam[1].role.coding[0].display | "Referring" |
| careTeam[1].role.text | "The referring physician" |
| supportingInfo[0].sequence | 1 |
| supportingInfo[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[0].category.coding[0].code | #billingnetworkcontractingstatus |
| supportingInfo[0].category.coding[0].display | "Billing Network Contracting Status" |
| supportingInfo[0].category.text | "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." |
| supportingInfo[0].code.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| supportingInfo[0].code.coding[0].code | #contracted |
| supportingInfo[0].code.coding[0].display | "Contracted" |
| supportingInfo[0].code.text | "Indicates the provider was contracted for the service" |
| supportingInfo[1].sequence | 2 |
| supportingInfo[1].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[1].category.coding[0].code | #clmrecvddate |
| supportingInfo[1].category.coding[0].display | "Claim Received Date" |
| supportingInfo[1].category.text | "Date the claim was received by the payer." |
| supportingInfo[1].timingDate | "2020-08-24" |
| diagnosis[0].sequence | 1 |
| diagnosis[0].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[0].diagnosisCodeableConcept.coding[0].code | #I70.249 |
| diagnosis[0].type[0].coding[0].system | "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" |
| diagnosis[0].type[0].coding[0].code | #principal |
| diagnosis[0].type[0].coding[0].display | "Principal Diagnosis" |
| diagnosis[0].type[0].text | "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." |
| diagnosis[1].sequence | 2 |
| diagnosis[1].diagnosisCodeableConcept.coding[0].system | "http://hl7.org/fhir/sid/icd-10-cm" |
| diagnosis[1].diagnosisCodeableConcept.coding[0].code | #L97.929 |
| diagnosis[1].type[0].coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" |
| diagnosis[1].type[0].coding[0].code | #secondary |
| diagnosis[1].type[0].coding[0].display | "secondary" |
| diagnosis[1].type[0].text | "Required when necessary to report additional diagnoses on professional and non-clinician claims" |
| insurance[0].focal | "true" |
| insurance[0].coverage.reference | "Coverage/CoverageEx1" |
| item[0].sequence | 1 |
| item[0].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[0].productOrService.coding[0].code | #75710 |
| item[0].servicedDate | "2020-08-04" |
| item[0].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[0].locationCodeableConcept.coding[0].code | #21 |
| item[0].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[0].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[0].category.coding[0].code | #submitted |
| item[0].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[0].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[0].adjudication[0].amount.value | 68.8 |
| item[0].adjudication[0].amount.currency | #USD |
| item[0].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[1].category.coding[0].code | #copay |
| item[0].adjudication[1].category.coding[0].display | "CoPay" |
| item[0].adjudication[1].category.text | "Patient Co-Payment" |
| item[0].adjudication[1].amount.value | 0.0 |
| item[0].adjudication[1].amount.currency | #USD |
| item[0].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[2].category.coding[0].code | #eligible |
| item[0].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[0].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[0].adjudication[2].amount.value | 34.8 |
| item[0].adjudication[2].amount.currency | #USD |
| item[0].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[3].category.coding[0].code | #deductible |
| item[0].adjudication[3].category.coding[0].display | "Deductible" |
| item[0].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[0].adjudication[3].amount.value | 0.0 |
| item[0].adjudication[3].amount.currency | #USD |
| item[0].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[4].category.coding[0].code | #benefit |
| item[0].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[0].adjudication[4].category.text | "Amount payable under the coverage" |
| item[0].adjudication[4].amount.value | 34.8 |
| item[0].adjudication[4].amount.currency | #USD |
| item[0].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[0].adjudication[5].category.coding[0].code | #noncovered |
| item[0].adjudication[5].category.coding[0].display | "Noncovered" |
| item[0].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[0].adjudication[5].amount.value | 0.0 |
| item[0].adjudication[5].amount.currency | #USD |
| item[0].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[0].adjudication[6].category.coding[0].code | #innetwork |
| item[0].adjudication[6].category.coding[0].display | "In Network" |
| item[0].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| item[1].sequence | 2 |
| item[1].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[1].productOrService.coding[0].code | #75710 |
| item[1].servicedDate | "2020-08-04" |
| item[1].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[1].locationCodeableConcept.coding[0].code | #21 |
| item[1].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[1].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[0].category.coding[0].code | #submitted |
| item[1].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[1].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[1].adjudication[0].amount.value | -68.8 |
| item[1].adjudication[0].amount.currency | #USD |
| item[1].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[1].category.coding[0].code | #copay |
| item[1].adjudication[1].category.coding[0].display | "CoPay" |
| item[1].adjudication[1].category.text | "Patient Co-Payment" |
| item[1].adjudication[1].amount.value | 0.0 |
| item[1].adjudication[1].amount.currency | #USD |
| item[1].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[2].category.coding[0].code | #eligible |
| item[1].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[1].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[1].adjudication[2].amount.value | -34.8 |
| item[1].adjudication[2].amount.currency | #USD |
| item[1].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[3].category.coding[0].code | #deductible |
| item[1].adjudication[3].category.coding[0].display | "Deductible" |
| item[1].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[1].adjudication[3].amount.value | 0.0 |
| item[1].adjudication[3].amount.currency | #USD |
| item[1].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[1].adjudication[4].category.coding[0].code | #benefit |
| item[1].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[1].adjudication[4].category.text | "Amount payable under the coverage" |
| item[1].adjudication[4].amount.value | -34.8 |
| item[1].adjudication[4].amount.currency | #USD |
| item[1].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[1].adjudication[5].category.coding[0].code | #noncovered |
| item[1].adjudication[5].category.coding[0].display | "Noncovered" |
| item[1].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[1].adjudication[5].amount.value | 0.0 |
| item[1].adjudication[5].amount.currency | #USD |
| item[1].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[1].adjudication[6].category.coding[0].code | #innetwork |
| item[1].adjudication[6].category.coding[0].display | "In Network" |
| item[1].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| item[2].sequence | 3 |
| item[2].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[2].productOrService.coding[0].code | #75710 |
| item[2].servicedDate | "2020-08-04" |
| item[2].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[2].locationCodeableConcept.coding[0].code | #21 |
| item[2].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[2].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[0].category.coding[0].code | #submitted |
| item[2].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[2].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[2].adjudication[0].amount.value | 68.8 |
| item[2].adjudication[0].amount.currency | #USD |
| item[2].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[1].category.coding[0].code | #copay |
| item[2].adjudication[1].category.coding[0].display | "CoPay" |
| item[2].adjudication[1].category.text | "Patient Co-Payment" |
| item[2].adjudication[1].amount.value | 0.0 |
| item[2].adjudication[1].amount.currency | #USD |
| item[2].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[2].category.coding[0].code | #eligible |
| item[2].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[2].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[2].adjudication[2].amount.value | 34.8 |
| item[2].adjudication[2].amount.currency | #USD |
| item[2].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[3].category.coding[0].code | #deductible |
| item[2].adjudication[3].category.coding[0].display | "Deductible" |
| item[2].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[2].adjudication[3].amount.value | 0.0 |
| item[2].adjudication[3].amount.currency | #USD |
| item[2].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[2].adjudication[4].category.coding[0].code | #benefit |
| item[2].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[2].adjudication[4].category.text | "Amount payable under the coverage" |
| item[2].adjudication[4].amount.value | 34.8 |
| item[2].adjudication[4].amount.currency | #USD |
| item[2].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[2].adjudication[5].category.coding[0].code | #noncovered |
| item[2].adjudication[5].category.coding[0].display | "Noncovered" |
| item[2].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[2].adjudication[5].amount.value | 0.0 |
| item[2].adjudication[5].amount.currency | #USD |
| item[2].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[2].adjudication[6].category.coding[0].code | #innetwork |
| item[2].adjudication[6].category.coding[0].display | "In Network" |
| item[2].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| item[3].sequence | 4 |
| item[3].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[3].productOrService.coding[0].code | #37228 |
| item[3].servicedDate | "2020-08-04" |
| item[3].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[3].locationCodeableConcept.coding[0].code | #21 |
| item[3].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[3].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[0].category.coding[0].code | #submitted |
| item[3].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[3].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[3].adjudication[0].amount.value | 751.2 |
| item[3].adjudication[0].amount.currency | #USD |
| item[3].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[1].category.coding[0].code | #copay |
| item[3].adjudication[1].category.coding[0].display | "CoPay" |
| item[3].adjudication[1].category.text | "Patient Co-Payment" |
| item[3].adjudication[1].amount.value | 0.0 |
| item[3].adjudication[1].amount.currency | #USD |
| item[3].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[2].category.coding[0].code | #eligible |
| item[3].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[3].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[3].adjudication[2].amount.value | 224.11 |
| item[3].adjudication[2].amount.currency | #USD |
| item[3].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[3].category.coding[0].code | #deductible |
| item[3].adjudication[3].category.coding[0].display | "Deductible" |
| item[3].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[3].adjudication[3].amount.value | 0.0 |
| item[3].adjudication[3].amount.currency | #USD |
| item[3].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[3].adjudication[4].category.coding[0].code | #benefit |
| item[3].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[3].adjudication[4].category.text | "Amount payable under the coverage" |
| item[3].adjudication[4].amount.value | 0.0 |
| item[3].adjudication[4].amount.currency | #USD |
| item[3].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[3].adjudication[5].category.coding[0].code | #noncovered |
| item[3].adjudication[5].category.coding[0].display | "Noncovered" |
| item[3].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[3].adjudication[5].amount.value | 224.11 |
| item[3].adjudication[5].amount.currency | #USD |
| item[3].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[3].adjudication[6].category.coding[0].code | #innetwork |
| item[3].adjudication[6].category.coding[0].display | "In Network" |
| item[3].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| item[4].sequence | 5 |
| item[4].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[4].productOrService.coding[0].code | #37228 |
| item[4].servicedDate | "2020-08-04" |
| item[4].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[4].locationCodeableConcept.coding[0].code | #21 |
| item[4].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[4].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[0].category.coding[0].code | #submitted |
| item[4].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[4].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[4].adjudication[0].amount.value | 751.2 |
| item[4].adjudication[0].amount.currency | #USD |
| item[4].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[1].category.coding[0].code | #copay |
| item[4].adjudication[1].category.coding[0].display | "CoPay" |
| item[4].adjudication[1].category.text | "Patient Co-Payment" |
| item[4].adjudication[1].amount.value | 0.0 |
| item[4].adjudication[1].amount.currency | #USD |
| item[4].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[2].category.coding[0].code | #eligible |
| item[4].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[4].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[4].adjudication[2].amount.value | 224.11 |
| item[4].adjudication[2].amount.currency | #USD |
| item[4].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[3].category.coding[0].code | #deductible |
| item[4].adjudication[3].category.coding[0].display | "Deductible" |
| item[4].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[4].adjudication[3].amount.value | 0.0 |
| item[4].adjudication[3].amount.currency | #USD |
| item[4].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[4].adjudication[4].category.coding[0].code | #benefit |
| item[4].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[4].adjudication[4].category.text | "Amount payable under the coverage" |
| item[4].adjudication[4].amount.value | 224.11 |
| item[4].adjudication[4].amount.currency | #USD |
| item[4].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[4].adjudication[5].category.coding[0].code | #noncovered |
| item[4].adjudication[5].category.coding[0].display | "Noncovered" |
| item[4].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[4].adjudication[5].amount.value | 0.0 |
| item[4].adjudication[5].amount.currency | #USD |
| item[4].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[4].adjudication[6].category.coding[0].code | #innetwork |
| item[4].adjudication[6].category.coding[0].display | "In Network" |
| item[4].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| item[5].sequence | 6 |
| item[5].productOrService.coding[0].system | "http://www.ama-assn.org/go/cpt" |
| item[5].productOrService.coding[0].code | #37228 |
| item[5].servicedDate | "2020-08-04" |
| item[5].locationCodeableConcept.coding[0].system | "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" |
| item[5].locationCodeableConcept.coding[0].code | #21 |
| item[5].locationCodeableConcept.text | "HOSPITAL - INPATIENT HOSPITAL" |
| item[5].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[0].category.coding[0].code | #submitted |
| item[5].adjudication[0].category.coding[0].display | "Submitted Amount" |
| item[5].adjudication[0].category.text | "The total submitted amount for the claim or group or line item." |
| item[5].adjudication[0].amount.value | -751.2 |
| item[5].adjudication[0].amount.currency | #USD |
| item[5].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[1].category.coding[0].code | #copay |
| item[5].adjudication[1].category.coding[0].display | "CoPay" |
| item[5].adjudication[1].category.text | "Patient Co-Payment" |
| item[5].adjudication[1].amount.value | 0.0 |
| item[5].adjudication[1].amount.currency | #USD |
| item[5].adjudication[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[2].category.coding[0].code | #eligible |
| item[5].adjudication[2].category.coding[0].display | "Eligible Amount" |
| item[5].adjudication[2].category.text | "Amount of the change which is considered for adjudication." |
| item[5].adjudication[2].amount.value | -224.11 |
| item[5].adjudication[2].amount.currency | #USD |
| item[5].adjudication[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[3].category.coding[0].code | #deductible |
| item[5].adjudication[3].category.coding[0].display | "Deductible" |
| item[5].adjudication[3].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| item[5].adjudication[3].amount.value | 0.0 |
| item[5].adjudication[3].amount.currency | #USD |
| item[5].adjudication[4].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[5].adjudication[4].category.coding[0].code | #benefit |
| item[5].adjudication[4].category.coding[0].display | "Benefit Amount" |
| item[5].adjudication[4].category.text | "Amount payable under the coverage" |
| item[5].adjudication[4].amount.value | 0.0 |
| item[5].adjudication[4].amount.currency | #USD |
| item[5].adjudication[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[5].adjudication[5].category.coding[0].code | #noncovered |
| item[5].adjudication[5].category.coding[0].display | "Noncovered" |
| item[5].adjudication[5].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| item[5].adjudication[5].amount.value | -224.11 |
| item[5].adjudication[5].amount.currency | #USD |
| item[5].adjudication[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| item[5].adjudication[6].category.coding[0].code | #innetwork |
| item[5].adjudication[6].category.coding[0].display | "In Network" |
| item[5].adjudication[6].category.text | "Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider" |
| total[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[0].category.coding[0].code | #submitted |
| total[0].category.coding[0].display | "Submitted Amount" |
| total[0].category.text | "The total submitted amount for the claim or group or line item." |
| total[0].amount.value | 820.0 |
| total[0].amount.currency | #USD |
| total[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[1].category.coding[0].code | #eligible |
| total[1].category.coding[0].display | "Eligible Amount" |
| total[1].category.text | "Amount of the change which is considered for adjudication." |
| total[1].amount.value | 258.91 |
| total[1].amount.currency | #USD |
| total[2].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[2].category.coding[0].code | #deductible |
| total[2].category.coding[0].display | "Deductible" |
| total[2].category.text | "Amount deducted from the eligible amount prior to adjudication." |
| total[2].amount.value | 0.0 |
| total[2].amount.currency | #USD |
| total[3].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[3].category.coding[0].code | #copay |
| total[3].category.coding[0].display | "CoPay" |
| total[3].category.text | "Patient Co-Payment" |
| total[3].amount.value | 0.0 |
| total[3].amount.currency | #USD |
| total[4].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[4].category.coding[0].code | #noncovered |
| total[4].category.coding[0].display | "Noncovered" |
| total[4].category.text | "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract." |
| total[4].amount.value | 0.0 |
| total[4].amount.currency | #USD |
| total[5].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[5].category.coding[0].code | #benefit |
| total[5].category.coding[0].display | "Benefit Amount" |
| total[5].category.text | "Amount payable under the coverage" |
| total[5].amount.value | 258.91 |
| total[5].amount.currency | #USD |
| total[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[6].category.coding[0].code | #memberliability |
| total[6].category.coding[0].display | "Member liability" |
| total[6].category.text | "The amount of the member's liability." |
| total[6].amount.value | 0.0 |
| total[6].amount.currency | #USD |
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.0.0 based on FHIR 4.0.1. Generated 2020-11-23
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