CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "ExplanationOfBenefit",
"id" : "EOBInpatient1",
"meta" : {
"lastUpdated" : "2019-12-12T09:14:11+00:00",
"profile" : [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.0"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBInpatient1\"> </a></p><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\">Resource ExplanationOfBenefit "EOBInpatient1" Updated "2019-12-12 09:14:11+0000" (Language "en-US") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional.html\">C4BB ExplanationOfBenefit Inpatient Institutional (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>subType</b>: Inpatient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBInstitutionalClaimSubType.html\">C4BB Institutional Claim SubType Code System</a>#inpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient2.html\">Patient/Patient2</a> " TEST"</p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-11-02 12:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">Organization/Payer1: XXX Health Plan</a> "Organization Payer 1"</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1: XXX Health Plan</a> "Orange Medical Group"</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Admission Period <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#admissionperiod)</span></p><p><b>timing</b>: 2011-05-23 --> 2011-05-25</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#clmrecvddate)</span></p><p><b>timing</b>: 2011-05-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Type of Bill <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#typeofbill)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCTypeOfBill.html\">AHA NUBC Type Of Bill Codes</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Point Of Origin <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#pointoforigin)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPointOfOriginNonnewborn.html\">AHA NUBC Point of Origin for Non-newborn</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Admission Type <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#admtype)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPriorityTypeOfAdmitOrVisit.html\">AHA NUBC Priority (Type) of Admission or Visit</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Discharge Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#discharge-status)</span></p><p><b>code</b>: 11 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPatientDischargeStatus.html\">AHA NUBC Patient Discharge Status Codes</a>#11)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Medical Record Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#medicalrecordnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: Patient Account Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#patientaccountnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td>Concussion w LOC of 30 minutes or less, init <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.0X1A)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-Coverage3.html\">Coverage/Coverage3</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td>*</td><td>1</td><td>Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#Dummy)</span></td><td>Not Applicable <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-data-absent-reason.html\">DataAbsentReason</a>#not-applicable)</span></td><td>2019-11-02</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidbypatient)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>620</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>2650</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidbypatient)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}
]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123412"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
],
"text" : "Institutional"
},
"subType" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
"code" : "inpatient"
}
],
"text" : "Inpatient"
},
"use" : "claim",
"patient" : {
"reference" : "Patient/Patient2"
},
"billablePeriod" : {
"start" : "2019-01-01",
"end" : "2019-10-31"
},
"created" : "2019-11-02T00:00:00+00:00",
"insurer" : {
"reference" : "Organization/Payer1",
"display" : "XXX Health Plan"
},
"provider" : {
"reference" : "Organization/ProviderOrganization1",
"display" : "XXX Health Plan"
},
"outcome" : "partial",
"supportingInfo" : [
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admissionperiod"
}
]
},
"timingPeriod" : {
"start" : "2011-05-23",
"end" : "2011-05-25"
}
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate"
}
]
},
"timingDate" : "2011-05-30"
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "typeofbill"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
"code" : "Dummy"
}
]
}
},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "pointoforigin"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/PointOfOrigin",
"code" : "Dummy"
}
]
}
},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admtype"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit",
"code" : "Dummy"
}
]
}
},
{
"sequence" : 7,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "discharge-status"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/PatDischargeStatus",
"code" : "11"
}
]
}
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "medicalrecordnumber"
}
]
},
"valueString" : "1234-234-1243-12345678901m"
},
{
"sequence" : 9,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "patientaccountnumber"
}
]
},
"valueString" : "1234-234-1243-12345678901a"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "S06.0X1A"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/Coverage3"
}
}
],
"item" : [
{
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "Dummy"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/data-absent-reason",
"code" : "not-applicable",
"display" : "Not Applicable"
}
]
},
"servicedDate" : "2019-11-02"
}
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code" : "benefitpaymentstatus"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code" : "billingnetworkstatus"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
],
"text" : "Payment Amount"
},
"amount" : {
"value" : 620,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 2650,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidbypatient"
}
],
"text" : "Patient Pay Amount"
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
],
"text" : "Payment Amount"
},
"amount" : {
"value" : 620,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 2650,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidbypatient"
}
],
"text" : "Patient Pay Amount"
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
}
]
}
IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#2.0.0 based on FHIR 4.0.1. Generated 2022-11-28
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