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

: EOB Outpatient Institutional - Example 1 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBOutpatient1"/>
  <meta>
    <lastUpdated value="2019-12-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name="EOBOutpatient1"> </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 &quot;EOBOutpatient1&quot; Updated &quot;2019-12-12 09:14:11+0000&quot;  (Language &quot;en-US&quot;) </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Outpatient-Institutional.html">C4BB ExplanationOfBenefit Outpatient 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>: Outpatient <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBInstitutionalClaimSubType.html">C4BB Institutional Claim SubType Code System</a>#outpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>billablePeriod</b>: 2019-01-01 --&gt; 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: Organization Payer 1</a> &quot;Organization Payer 1&quot;</p><p><b>provider</b>: <a href="Organization-ProviderOrganization1.html">Organization/ProviderOrganization1: Orange Medical Group</a> &quot;Orange Medical Group&quot;</p><p><b>outcome</b>: partial</p><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td>*</td><td>1</td><td><a href="Organization-ProviderOrganization1.html">Organization/ProviderOrganization1</a> &quot;Orange Medical Group&quot;</td><td>Rendering provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimCareTeamRole.html">C4BB Claim Care Team Role Code System</a>#rendering)</span></td><td>Oncology Clinical Nurse Specialist <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (provider-taxonomy#364SX0200X)</span></td></tr></table><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</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>: 2019-11-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</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>: 4</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>: 5</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>: 6</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>: Dummy <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>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</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>: 8</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>Patient Reason for Visit <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBClaimDiagnosisType.html">C4BB Claim Diagnosis Type Code System</a>#patientreasonforvisit)</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>: 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>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
    <value value="AW123412341234123412341234123412"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
    <text value="Institutional"/>
  </type>
  <subType>
    <coding>
      <system
              value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
      <code value="outpatient"/>
    </coding>
    <text value="Outpatient"/>
  </subType>
  <use value="claim"/>
  <patient>
    <reference value="Patient/Patient2"/>
  </patient>
  <billablePeriod>
    <start value="2019-01-01"/>
    <end value="2019-10-31"/>
  </billablePeriod>
  <created value="2019-11-02T00:00:00+00:00"/>
  <insurer>
    <reference value="Organization/Payer1"/>
    <display value="Organization Payer 1"/>
  </insurer>
  <provider>
    <reference value="Organization/ProviderOrganization1"/>
    <display value="Orange Medical Group"/>
  </provider>
  <outcome value="partial"/>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Organization/ProviderOrganization1"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="rendering"/>
        <display value="Rendering provider"/>
      </coding>
    </role>
    <qualification>
      <coding>
        <system value="http://nucc.org/provider-taxonomy"/>
        <code value="364SX0200X"/>
        <display value="Oncology Clinical Nurse Specialist"/>
      </coding>
    </qualification>
  </careTeam>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2019-11-30"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="typeofbill"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="4"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="pointoforigin"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/PointOfOrigin"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="5"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="admtype"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="6"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="discharge-status"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/PatDischargeStatus"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="7"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="medicalrecordnumber"/>
      </coding>
    </category>
    <valueString value="1234-234-1243-12345678901m"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="8"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="patientaccountnumber"/>
      </coding>
    </category>
    <valueString value="1234-234-1243-12345678901a"/>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="S06.0X1A"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="patientreasonforvisit"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/Coverage3"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="Dummy"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
        <code value="not-applicable"/>
        <display value="Not Applicable"/>
      </coding>
    </productOrService>
    <servicedDate value="2019-11-02"/>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Payment Amount"/>
    </category>
    <amount>
      <value value="620"/>
      <currency value="USD"/>
    </amount>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidbypatient"/>
      </coding>
      <text value="Patient Pay Amount"/>
    </category>
    <amount>
      <value value="0"/>
    </amount>
  </adjudication>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Payment Amount"/>
    </category>
    <amount>
      <value value="620"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="2650"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidbypatient"/>
      </coding>
      <text value="Patient Pay Amount"/>
    </category>
    <amount>
      <value value="0"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>