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@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> . @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:id [ fhir:v "EOBProfessional2"] ; # fhir:meta [ fhir:lastUpdated [ fhir:v "2020-10-20T14:46:05-04:00"^^xsd:dateTime ] ; fhir:source [ fhir:v "Organization/PayerOrganizationExample1"^^xsd:anyURI ] ; ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.1.0"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.1.0> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit EOBProfessional2</b></p><a name=\"EOBProfessional2\"> </a><a name=\"hcEOBProfessional2\"> </a><a name=\"EOBProfessional2-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2020-10-20 14:46:05-0400; </p><p style=\"margin-bottom: 0px\">Information Source: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&canonical=http://hl7.org/fhir/us/core/Organization/PayerOrganizationExample1\">Organization/PayerOrganizationExample1</a></p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Professional-NonClinician.html\">C4BB ExplanationOfBenefit Professional NonClinicianversion: null2.1.0)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/ProfessionalEOBExample1</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)</a></p><p><b>billablePeriod</b>: 2020-08-04 --> 2020-08-04</p><p><b>created</b>: 2020-08-24 00:00:00-0400</p><p><b>insurer</b>: <a href=\"Organization-Payer2.html\">UPMC Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization Orange Medical Group</a></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href=\"Organization-ProviderOrganization1.html\">Organization Orange Medical Group</a></td></tr></table><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner1.html\">Practitioner John Smith </a></p><p><b>role</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claimcareteamrole primary}\">The primary care provider.</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner2.html\">Practitioner 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><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Date the claim was received by the payer.</span></td><td>2020-08-24</td></tr></table><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm I70.249}\">Athscl native arteries of left leg w ulceration of unsp site</span></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm L97.929}\">Non-prs chronic ulc unsp prt of l low leg w unsp severity</span></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType secondary}\">Required when necessary to report additional diagnoses on professional and non-clinician claims</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-Coverage1.html\">Coverage: identifier = 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; relationship = Self; period = 2020-01-01 --> (ongoing); network = GR5-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 75710}\">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>68.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 75710}\">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-68.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 75710}\">Angiography, extremity, unilateral, radiological supervision and interpretation</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>68.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>34.8</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 37228}\">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>751.2</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>224.11</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>224.11</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 37228}\">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>751.2</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>224.11</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>224.11</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 37228}\">Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></p><p><b>reason</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p></blockquote><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-751.2</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-224.11</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>-224.11</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}\">Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">Indicates the provider was in network for the service</span></td></tr></table><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>820</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>258.91</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>258.91</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></div>"^^rdf:XMLLiteral ] ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"^^xsd:anyURI ] ; fhir:code [ fhir:v "uc" ] ; fhir:display [ fhir:v "Unique Claim ID" ] ] ) ; fhir:text [ fhir:v "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" ] ] ; fhir:system [ fhir:v "https://www.upmchealthplan.com/fhir/EOBIdentifier"^^xsd:anyURI ] ; fhir:value [ fhir:v "ProfessionalEOBExample1" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "professional" ] ] ) ; fhir:text [ fhir:v "Professional" ] ] ; # fhir:use [ fhir:v "claim"] ; # fhir:patient [ fhir:reference [ fhir:v "Patient/Patient1" ] ] ; # fhir:billablePeriod [ fhir:start [ fhir:v "2020-08-04"^^xsd:date ] ; fhir:end [ fhir:v "2020-08-04"^^xsd:date ] ] ; # fhir:created [ fhir:v "2020-08-24T00:00:00-04:00"^^xsd:dateTime] ; # fhir:insurer [ fhir:reference [ fhir:v "Organization/Payer2" ] ; fhir:display [ fhir:v "UPMC Health Plan" ] ] ; # fhir:provider [ fhir:reference [ fhir:v "Organization/ProviderOrganization1" ] ] ; # fhir:payee [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ; fhir:code [ fhir:v "provider" ] ; fhir:display [ fhir:v "Provider" ] ] ) ; fhir:text [ fhir:v "Any benefit payable will be paid to the provider (Assignment of Benefit)." ] ] ; fhir:party [ fhir:reference [ fhir:v "Organization/ProviderOrganization1" ] ] ] ; # fhir:outcome [ fhir:v "complete"] ; # fhir:careTeam ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:provider [ fhir:reference [ fhir:v "Practitioner/Practitioner1" ] ] ; fhir:role [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claimcareteamrole"^^xsd:anyURI ] ; fhir:version [ fhir:v "1.0.0" ] ; fhir:code [ fhir:v "primary" ] ; fhir:display [ fhir:v "Primary provider" ] ] ) ; fhir:text [ fhir:v "The primary care provider." ] ] ] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:provider [ fhir:reference [ fhir:v "Practitioner/Practitioner2" ] ] ; fhir:role [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"^^xsd:anyURI ] ; fhir:code [ fhir:v "referring" ] ; fhir:display [ fhir:v "Referring" ] ] ) ; fhir:text [ fhir:v "The referring physician" ] ] ] ) ; # fhir:supportingInfo ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ; fhir:code [ fhir:v "clmrecvddate" ] ; fhir:display [ fhir:v "Claim Received Date" ] ] ) ; fhir:text [ fhir:v "Date the claim was received by the payer." ] ] ; fhir:timing [ a fhir:date ; fhir:v "2020-08-24"^^xsd:date ] ] ) ; # fhir:diagnosis ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "I70.249" ] ] ) ] ; ( fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"^^xsd:anyURI ] ; fhir:code [ fhir:v "principal" ] ; fhir:display [ fhir:v "Principal Diagnosis" ] ] ) ; fhir:text [ fhir:v "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." ] ] ) ] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "L97.929" ] ] ) ] ; ( fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"^^xsd:anyURI ] ; fhir:code [ fhir:v "secondary" ] ; fhir:display [ fhir:v "secondary" ] ] ) ; fhir:text [ fhir:v "Required when necessary to report additional diagnoses on professional and non-clinician claims" ] ] ) ] ) ; # fhir:insurance ( [ fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:coverage [ fhir:reference [ fhir:v "Coverage/Coverage1" ] ] ] ) ; # fhir:item ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "75710" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "68.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "75710" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "-68.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "-34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "-34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "75710" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "68.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "34.8"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "37228" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "751.2"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "5"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "37228" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "751.2"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "6"^^xsd:positiveInteger ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "37228" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2020-08-04"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ; fhir:code [ fhir:v "21" ] ] ) ; fhir:text [ fhir:v "HOSPITAL - INPATIENT HOSPITAL" ] ] ; ( fhir:adjudication [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "-751.2"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "-224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "-224.11"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) ; # fhir:adjudication ( [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ; fhir:code [ fhir:v "billingnetworkstatus" ] ; fhir:display [ fhir:v "Billing Network Status" ] ] ) ; fhir:text [ fhir:v "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." ] ] ; fhir:reason [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "innetwork" ] ; fhir:display [ fhir:v "In Network" ] ] ) ; fhir:text [ fhir:v "Indicates the provider was in network for the service" ] ] ] ) ; # fhir:total ( [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ; fhir:text [ fhir:v "The total submitted amount for the claim or group or line item." ] ] ; fhir:amount [ fhir:value [ fhir:v "820"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligible" ] ; fhir:display [ fhir:v "Eligible Amount" ] ] ) ; fhir:text [ fhir:v "Amount of the change which is considered for adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "258.91"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "deductible" ] ; fhir:display [ fhir:v "Deductible" ] ] ) ; fhir:text [ fhir:v "Amount deducted from the eligible amount prior to adjudication." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "CoPay" ] ] ) ; fhir:text [ fhir:v "Patient Co-Payment" ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "noncovered" ] ; fhir:display [ fhir:v "Noncovered" ] ] ) ; fhir:text [ fhir:v "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:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "benefit" ] ; fhir:display [ fhir:v "Benefit Amount" ] ] ) ; fhir:text [ fhir:v "Amount payable under the coverage" ] ] ; fhir:amount [ fhir:value [ fhir:v "258.91"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "memberliability" ] ; fhir:display [ fhir:v "Member liability" ] ] ) ; fhir:text [ fhir:v "The amount of the member's liability." ] ] ; fhir:amount [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) . #
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2025-02-18
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