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 "EOBProfessional2" Updated "2020-10-20 02:46:05-0400"
Information Source: Organization/PayerOrganizationExample1!
Profile: C4BB ExplanationOfBenefit Professional NonClinician (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: ProfessionalEOBExample1
status: active
type: Professional (Claim Type Codes#professional)
use: claim
patient: Patient/Patient1 " EXAMPLE1"
billablePeriod: 2020-08-04 --> 2020-08-04
created: 2020-08-24 12:00:00-0400
insurer: Organization/Payer2: UPMC Health Plan "UPMC Health Plan"
provider: Organization/ProviderOrganization1 "Orange Medical Group"
| - | Type | Party |
| * | Any benefit payable will be paid to the provider (Assignment of Benefit). (Claim Payee Type Codes#provider "Provider") | Organization/ProviderOrganization1 "Orange Medical Group" |
outcome: complete
careTeam
sequence: 1
provider: Organization/ProviderOrganization1 "Orange Medical Group"
role: The primary care provider. (Claim Care Team Role Codes#primary "Primary provider")
careTeam
sequence: 2
provider: Practitioner/Practitioner1 " SMITH"
role: The referring physician (C4BB Claim Care Team Role Code System#referring "Referring")
| - | Sequence | Category | Timing[x] |
| * | 1 | Date the claim was received by the payer. (C4BB Supporting Info Type Code System#clmrecvddate "Claim Received Date") | 2020-08-24 |
diagnosis
sequence: 1
diagnosis: Athscl native arteries of left leg w ulceration of unsp site (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#I70.249)
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: Non-prs chronic ulc unsp prt of l low leg w unsp severity (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#L97.929)
type: Required when necessary to report additional diagnoses on professional and non-clinician claims (C4BB Claim Diagnosis Type Code System#secondary "secondary")
| - | Focal | Coverage |
| * | true | Coverage/Coverage1 |
item
sequence: 1
productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 68.8 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 * 34.8 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 * 34.8 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
productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * -68.8 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 * -34.8 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 * -34.8 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: 3
productOrService: 75710 (Current Procedural Terminology (CPT®)#75710)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 68.8 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 * 34.8 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 * 34.8 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: 4
productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 751.2 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 * 224.11 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 * 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 * 224.11 USD
item
sequence: 5
productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 751.2 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 * 224.11 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 * 224.11 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: 6
productOrService: 37228 (Current Procedural Terminology (CPT®)#37228)
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL (CMS Place of Service Codes (POS)#21)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * -751.2 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 * -224.11 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 * 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 * -224.11 USD
| - | Category | Reason |
| * | Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. (C4BB Adjudication Discriminator Code System#billingnetworkstatus "Billing Network Status") | Indicates the provider was in network for the service (C4BB Payer Adjudication Status Code System#innetwork "In Network") |
total
category: The total submitted amount for the claim or group or line item. (Adjudication Value Codes#submitted "Submitted Amount")
Amounts
- Value Currency * 820 USD
total
category: Amount of the change which is considered for adjudication. (Adjudication Value Codes#eligible "Eligible Amount")
Amounts
- Value Currency * 258.91 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 * 258.91 USD
total
category: The amount of the member's liability. (C4BB Adjudication Code System#memberliability "Member liability")
Amounts
- Value Currency * 0 USD
Instance: EOBProfessional2
InstanceOf: ExplanationOfBenefit
Title: "EOB Professional - Example 2"
Description: "EOB Professional - Example 2"
Usage: #example
* meta.lastUpdated = "2020-10-20T14:46:05-04:00"
* meta.source = "Organization/PayerOrganizationExample1"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|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 = "ProfessionalEOBExample1"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#professional
* text = "Professional"
* use = #claim
* patient = Reference(Patient1)
* billablePeriod.start = "2020-08-04"
* billablePeriod.end = "2020-08-04"
* created = "2020-08-24T00:00:00-04:00"
* insurer = Reference(Payer2) "UPMC Health Plan"
* provider = Reference(ProviderOrganization1)
* 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(ProviderOrganization1)
* outcome = #complete
* careTeam[0].sequence = 1
* careTeam[=].provider = Reference(ProviderOrganization1)
* careTeam[=].role = http://terminology.hl7.org/CodeSystem/claimcareteamrole#primary "Primary provider"
* text = "The primary care provider."
* careTeam[+].sequence = 2
* careTeam[=].provider = Reference(Practitioner1)
* 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 "Claim Received Date"
* text = "Date the claim was received by the payer."
* supportingInfo.timingDate = "2020-08-24"
* diagnosis[0].sequence = 1
* diagnosis[=].diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#I70.249
* 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#L97.929
* diagnosis[=].type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType#secondary "secondary"
* text = "Required when necessary to report additional diagnoses on professional and non-clinician claims"
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item[0].sequence = 1
* item[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 68.8
* 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 = 34.8
* 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 = 34.8
* 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[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = -68.8
* 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 = -34.8
* 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 = -34.8
* 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 = 3
* item[=].productOrService = http://www.ama-assn.org/go/cpt#75710
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 68.8
* 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 = 34.8
* 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 = 34.8
* 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 = 4
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 751.2
* 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 = 224.11
* 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 = 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 = 224.11
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 5
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = 751.2
* 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 = 224.11
* 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 = 224.11
* 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 = 6
* item[=].productOrService = http://www.ama-assn.org/go/cpt#37228
* item[=].servicedDate = "2020-08-04"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#21
* text = "HOSPITAL - INPATIENT HOSPITAL"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* text = "The total submitted amount for the claim or group or line item."
* item[=].adjudication[=].amount.value = -751.2
* 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 = -224.11
* 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 = 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 = -224.11
* item[=].adjudication[=].amount.currency = #USD
* adjudication.category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus "Billing Network Status"
* text = "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
* adjudication.reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork "In Network"
* text = "Indicates the provider was in network for the service"
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted "Submitted Amount"
* total[=].category.text = "The total submitted amount for the claim or group or line item."
* total[=].amount.value = 820
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#eligible "Eligible Amount"
* text = "Amount of the change which is considered for adjudication."
* total[=].amount.value = 258.91
* 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 = 258.91
* 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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