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 
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "EOBOutpatient2" Updated "2020-10-13 11:10:24-0400"
Information Source: Organization/PayerOrganizationExample1!
Profile: C4BB ExplanationOfBenefit Outpatient Institutional (version 2.0.0)
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: OutpatientEOBExample1
status: active
type: Institutional (Claim Type Codes#institutional)
subType: Outpatient (C4BB Institutional Claim SubType Code System#outpatient)
use: claim
patient: Patient/Patient1 " EXAMPLE1"
billablePeriod: 2020-09-29 --> 2020-09-29
created: 2020-10-10 12:00:00-0400
insurer: Organization/Payer2: UPMC Health Plan "UPMC Health Plan"
provider: Organization/ProviderOrganization5 "Black Medical Group"
| - | Type | Party |
| * | Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider") | Organization/ProviderOrganization6 "White Medical Group" |
outcome: complete
careTeam
sequence: 1
provider: Practitioner/Practitioner1 " SMITH"
role: The attending physician (C4BB Claim Care Team Role Code System#attending "Attending")
careTeam
sequence: 2
provider: Practitioner/Practitioner3 " WILLIAMS"
role: The referring physician (C4BB Claim Care Team Role Code System#referring "Referring")
| - | Sequence | Category | Timing[x] |
| * | 1 | Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate) | 2020-10-10 |
diagnosis
sequence: 1
diagnosis: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. (Example Diagnosis Type Codes#principal "Principal Diagnosis")
diagnosis
sequence: 2
diagnosis: Orthostatic hypotension (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I95.1)
type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type Code System#other "Other")
diagnosis
sequence: 3
diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#L97.529)
type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type Code System#other "Other")
diagnosis
sequence: 4
diagnosis: Peripheral vascular disease, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I73.9)
type: Required when other conditions coexist or develop subsequently during the treatment (C4BB Claim Diagnosis Type Code System#other "Other")
| - | Focal | Coverage |
| * | true | Coverage/Coverage1 |
item
sequence: 1
revenue: 0551 (AHA NUBC Revenue Codes#0551)
productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)
serviced: 2020-09-29
location: HOME (CMS Place of Service Codes (POS)#12)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 84.4 USD adjudication
category: Patient Co-Payment (Adjudication Value Codes#copay "CoPay")
Amounts
- Value Currency * 0 USD adjudication
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 56.52 USD adjudication
category: Amount deducted from the eligible amount prior to adjudication. (Adjudication Value Codes#deductible "Deductible")
Amounts
- Value Currency * 0 USD adjudication
category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")
Amounts
- Value Currency * 56.52 USD adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. (C4BB Adjudication Code System#noncovered "Noncovered")
Amounts
- Value Currency * 0 USD
item
sequence: 2
revenue: 0023 (AHA NUBC Revenue Codes#0023)
productOrService: 99231 (Current Procedural Terminology (CPT®)#99231)
serviced: 2020-09-29
location: HOME (CMS Place of Service Codes (POS)#12)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 0 USD adjudication
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. (C4BB Adjudication Code System#noncovered "Noncovered")
Amounts
- Value Currency * 0 USD
| - | Category | Reason |
| * | Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
total
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 56.52 USD
total
category: Amount deducted from the eligible amount prior to adjudication. (Adjudication Value Codes#deductible "Deductible")
Amounts
- Value Currency * 0 USD
total
category: Patient Co-Payment (Adjudication Value Codes#copay "CoPay")
Amounts
- Value Currency * 0 USD
total
category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. (C4BB Adjudication Code System#noncovered "Noncovered")
Amounts
- Value Currency * 0 USD
total
category: Amount payable under the coverage (Adjudication Value Codes#benefit "Benefit Amount")
Amounts
- Value Currency * 56.52 USD
total
category: The amount of the member's liability. (C4BB Adjudication Code System#memberliability "Member liability")
Amounts
- Value Currency * 0 USD
Instance: EOBOutpatient2
InstanceOf: ExplanationOfBenefit
Title: "EOB Outpatient Institutional - Example 2"
Description: "EOB Outpatient Institutional - Example 2"
Usage: #example
* meta.lastUpdated = "2020-10-13T11:10:24-04:00"
* meta.source = "Organization/PayerOrganizationExample1"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0"
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc "Unique Claim ID"
* text = "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
* identifier.system = "https://www.upmchealthplan.com/fhir/EOBIdentifier"
* identifier.value = "OutpatientEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
* text = "Institutional"
* subType = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType#outpatient
* text = "Outpatient"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2020-09-29"
* billablePeriod.end = "2020-09-29"
* created = "2020-10-10T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization5)
* payee.type = http://terminology.hl7.org/CodeSystem/payeetype#provider "Provider"
* text = "Any benefit payable will be paid to the provider (Assignment of Benefit)."
* payee.party = Reference(ProviderOrganization6)
* outcome = #complete
* careTeam[0].sequence = 1
* careTeam[=].provider = Reference(Practitioner1)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#attending "Attending"
* text = "The attending physician"
* careTeam[+].sequence = 2
* careTeam[=].provider = Reference(Practitioner3)
* careTeam[=].role = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole#referring "Referring"
* text = "The referring physician"
* supportingInfo.sequence = 1
* supportingInfo.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo.timingDate = "2020-10-10"
* diagnosis[0].sequence = 1
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I95.1
* diagnosis[=].type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal "Principal Diagnosis"
* text = "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
* diagnosis[+].sequence = 2
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I95.1
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
* text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+].sequence = 3
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#L97.529
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
* text = "Required when other conditions coexist or develop subsequently during the treatment"
* diagnosis[+].sequence = 4
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I73.9
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#other "Other"
* text = "Required when other conditions coexist or develop subsequently during the treatment"
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0551
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedDate = "2020-09-29"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#12
* text = "HOME"
* item[=].adjudication[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* item[=].adjudication[=].category.text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 84.4
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#copay "CoPay"
* text = "Patient Co-Payment"
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* text = "Amount of the change which is considered for adjudication."
* item[=].adjudication[=].amount.value = 56.52
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
* text = "Amount deducted from the eligible amount prior to adjudication."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
* text = "Amount payable under the coverage"
* item[=].adjudication[=].amount.value = 56.52
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#noncovered "Noncovered"
* text = "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 2
* item[=].revenue = https://www.nubc.org/CodeSystem/RevenueCodes#0023
* item[=].productOrService = http://www.ama-assn.org/go/cpt#99231
* item[=].servicedDate = "2020-09-29"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#12
* text = "HOME"
* item[=].adjudication[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* item[=].adjudication[=].category.text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* item[=].adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#noncovered "Noncovered"
* text = "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
* item[=].adjudication[=].amount.value = 0
* item[=].adjudication[=].amount.currency = #USD
* adjudication.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication.reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* total[=].category.text = "Amount of the change which is considered for adjudication."
* total[=].amount.value = 56.52
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#deductible "Deductible"
* text = "Amount deducted from the eligible amount prior to adjudication."
* total[=].amount.value = 0
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#copay "CoPay"
* text = "Patient Co-Payment"
* total[=].amount.value = 0
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#noncovered "Noncovered"
* text = "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
* total[=].amount.value = 0
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit "Benefit Amount"
* text = "Amount payable under the coverage"
* total[=].amount.value = 56.52
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#memberliability "Member liability"
* text = "The amount of the member's liability."
* total[=].amount.value = 0
* total[=].amount.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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