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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 "EOBProfessionalTransportation1"] ; # fhir:meta [ fhir:lastUpdated [ fhir:v "2022-09-10T14:46:05-04:00"^^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 EOBProfessionalTransportation1</b></p><a name=\"EOBProfessionalTransportation1\"> </a><a name=\"hcEOBProfessionalTransportation1\"> </a><a name=\"EOBProfessionalTransportation1-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: 2022-09-10 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/ProfessionalTransportationEOBExample1</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>: 2022-09-10 --> (ongoing)</p><p><b>created</b>: 2022-09-10 14:46:05-0400</p><p><b>insurer</b>: <a href=\"Organization-Payer2.html\">UPMC Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-ProviderTransportationOrganization1.html\">Organization ABC Ambulance Services</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-ProviderTransportationOrganization1.html\">Organization ABC Ambulance Services</a></td></tr></table><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Date the claim was received by the payer.</span></p><p><b>timing</b>: 2022-09-11</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientweight}\">Patient Weight</span></p><p><b>value</b>: 160 [lb_av]</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType ambulancetransportreason}\">Ambulance Transport Reason</span></p><p><b>reason</b>: <a href=\"http://terminology.hl7.org/6.2.0/CodeSystem-X12AmbulanceTransportReasonCodes.html#X12AmbulanceTransportReasonCodes-B\">X12 Ambulance Transport Reason Codes B</a>: Patient was transported for the benefit of a preferred physician</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType transportationdistance}\">Transportation Distance</span></p><p><b>value</b>: 21 [mi_i]</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType transportationdistance}\">Transportation Distance</span></p><p><b>value</b>: 22 [mi_i]</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType roudtrippurpose}\">Round Trip Purpose</span></p><p><b>value</b>: Trip to facility and then back home</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType stretcherpurpose}\">Stretcher Purpose</span></p><p><b>value</b>: Patient could not walk</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType pickuplocation}\">Pick-up Location</span></p><p><b>value</b>: Patient home; Pittsburgh; PA,15222</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dropofflocation}\">Drop-off Location</span></p><p><b>value</b>: Orange Medical Group; Pittsburgh; PA,15222</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType pickuplocation}\">Pick-up Location</span></p><p><b>value</b>: Orange Medical Group; Pittsburgh; PA,15222</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dropofflocation}\">Drop-off Location</span></p><p><b>value</b>: Patient home; Pittsburgh; PA,15222</p></blockquote><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><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></td><td><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></td></tr></table><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>informationSequence</b>: 2, 3, 4, 6, 7, 10, 11</p><p><b>productOrService</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets A0428}\">Ambulance service, basic life support, non-emergency transport (BLS)</span></p><p><b>serviced</b>: 2022-09-10</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 41}\">Ambulance - Land</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>40.35</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>40.35</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>40.35</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>informationSequence</b>: 2, 3, 5, 6, 7, 8, 9</p><p><b>productOrService</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets A0428}\">Ambulance service, basic life support, non-emergency transport (BLS)</span></p><p><b>serviced</b>: 2022-09-10</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 41}\">Ambulance - Land</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>42.62</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>42.62</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>42.62</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>82.97</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>82.97</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>82.97</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.example.com/fhir/EOBIdentifier"^^xsd:anyURI ] ; fhir:value [ fhir:v "ProfessionalTransportationEOBExample1" ] ] ) ; # 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 "2022-09-10"^^xsd:date ] ] ; # fhir:created [ fhir:v "2022-09-10T14:46:05-04:00"^^xsd:dateTime] ; # fhir:insurer [ fhir:reference [ fhir:v "Organization/Payer2" ] ; fhir:display [ fhir:v "UPMC Health Plan" ] ] ; # fhir:provider [ fhir:reference [ fhir:v "Organization/ProviderTransportationOrganization1" ] ] ; # 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/ProviderTransportationOrganization1" ] ] ] ; # fhir:outcome [ fhir:v "complete"] ; # 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 "2022-09-11"^^xsd:date ] ] [ fhir:sequence [ fhir:v "2"^^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 "patientweight" ] ] ) ] ; fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "160"^^xsd:decimal ] ; fhir:unit [ fhir:v "[lb_av]" ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ] ] [ fhir:sequence [ fhir:v "3"^^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 "ambulancetransportreason" ] ] ) ] ; fhir:reason [ fhir:system [ fhir:v "https://x12.org/codesystem.x12.org/ambulance-transport-reason-codes"^^xsd:anyURI ] ; fhir:code [ fhir:v "B" ] ; fhir:display [ fhir:v "Patient was transported for the benefit of a preferred physician" ] ] ] [ fhir:sequence [ fhir:v "4"^^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 "transportationdistance" ] ] ) ] ; fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "21"^^xsd:decimal ] ; fhir:unit [ fhir:v "[mi_i]" ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ] ] [ fhir:sequence [ fhir:v "5"^^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 "transportationdistance" ] ] ) ] ; fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "22"^^xsd:decimal ] ; fhir:unit [ fhir:v "[mi_i]" ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ] ] [ fhir:sequence [ fhir:v "6"^^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 "roudtrippurpose" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Trip to facility and then back home" ] ] [ fhir:sequence [ fhir:v "7"^^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 "stretcherpurpose" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Patient could not walk" ] ] [ fhir:sequence [ fhir:v "8"^^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 "pickuplocation" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Patient home; Pittsburgh; PA,15222" ] ] [ fhir:sequence [ fhir:v "9"^^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 "dropofflocation" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Orange Medical Group; Pittsburgh; PA,15222" ] ] [ fhir:sequence [ fhir:v "10"^^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 "pickuplocation" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Orange Medical Group; Pittsburgh; PA,15222" ] ] [ fhir:sequence [ fhir:v "11"^^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 "dropofflocation" ] ] ) ] ; fhir:value [ a fhir:string ; fhir:v "Patient home; Pittsburgh; PA,15222" ] ] ) ; # 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: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:informationSequence [ fhir:v "2"^^xsd:positiveInteger ] [ fhir:v "3"^^xsd:positiveInteger ] [ fhir:v "4"^^xsd:positiveInteger ] [ fhir:v "6"^^xsd:positiveInteger ] [ fhir:v "7"^^xsd:positiveInteger ] [ fhir:v "10"^^xsd:positiveInteger ] [ fhir:v "11"^^xsd:positiveInteger ] ) ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ; fhir:code [ fhir:v "A0428" ] ; fhir:display [ fhir:v "Ambulance service, basic life support, non-emergency transport (BLS)" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2022-09-10"^^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 "41" ] ] ) ; fhir:text [ fhir:v "Ambulance - Land" ] ] ; ( 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 "40.35"^^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 "40.35"^^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 "40.35"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; ( fhir:informationSequence [ fhir:v "2"^^xsd:positiveInteger ] [ fhir:v "3"^^xsd:positiveInteger ] [ fhir:v "5"^^xsd:positiveInteger ] [ fhir:v "6"^^xsd:positiveInteger ] [ fhir:v "7"^^xsd:positiveInteger ] [ fhir:v "8"^^xsd:positiveInteger ] [ fhir:v "9"^^xsd:positiveInteger ] ) ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ; fhir:code [ fhir:v "A0428" ] ; fhir:display [ fhir:v "Ambulance service, basic life support, non-emergency transport (BLS)" ] ] ) ] ; fhir:serviced [ a fhir:date ; fhir:v "2022-09-10"^^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 "41" ] ] ) ; fhir:text [ fhir:v "Ambulance - Land" ] ] ; ( 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 "42.62"^^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 "42.62"^^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 "42.62"^^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 "82.97"^^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 "82.97"^^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 "82.97"^^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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