CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.1.0 - STU1 Update

This page is part of the CARIN Blue Button Implementation Guide (v1.1.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Outpatient Institutional - Example 1

Generated Narrative

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

subType: Outpatient

use: claim

patient: Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; unknown

billablePeriod: 2020-09-29 --> 2020-09-29

created: Oct 10, 2020 4:00:00 AM

insurer: UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; Payer; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762

provider: Generated Summary: National Provider Identifier: 5556667770; active; name: Black Medical Group

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit).Generated Summary: National Provider Identifier: 0001112220; active; name: White Medical Group

outcome: complete

careTeam

sequence: 1

provider: Generated Summary: National Provider Identifier: 6667778880; active; John Smith

role: The attending physician

careTeam

sequence: 2

provider: Generated Summary: National Provider Identifier: 7778889990; active; Jane Williams

role: The referring physician

supportingInfo

sequence: 1

category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.

code: Indicates the provider was contracted for the service

supportingInfo

sequence: 2

category: Date the claim was received by the payer.

timing: 2020-10-10

diagnosis

sequence: 1

diagnosis: Orthostatic hypotension

type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.

diagnosis

sequence: 2

diagnosis: Orthostatic hypotension

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 3

diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 4

diagnosis: Peripheral vascular disease, unspecified

type: Required when other conditions coexist or develop subsequently during the treatment

Insurances

-FocalCoverage
*trueGenerated Summary: language: en-US; 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; Self; period: 2020-01-01 --> (ongoing); network: GR5-HMO DEDUCTIBLE

item

sequence: 1

revenue: 0551

productOrService: 99231

serviced: 2020-09-29

location: HOME

adjudication

category: The total submitted amount for the claim or group or line item.

adjudication

category: Patient Co-Payment

adjudication

category: Amount of the change which is considered for adjudication.

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

adjudication

category: Amount payable under the coverage

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.

item

sequence: 2

revenue: 0023

productOrService: 99231

serviced: 2020-09-29

location: HOME

adjudication

category: The total submitted amount for the claim or group or line item.

adjudication

category: Patient Co-Payment

adjudication

category: Amount of the change which is considered for adjudication.

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

adjudication

category: Amount payable under the coverage

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.

total

category: The total submitted amount for the claim or group or line item.

total

category: Amount of the change which is considered for adjudication.

total

category: Amount deducted from the eligible amount prior to adjudication.

total

category: Patient Co-Payment

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.

total

category: Amount payable under the coverage

total

category: The amount of the member's liability.

total

category: Out Of Network

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "OutpatientEOBExample1"
meta.lastUpdated "2020-10-13T11:10:24-04:00"
meta.source "Organization/PayerOrganizationExample1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional"
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].display "Unique Claim ID"
identifier[0].type.text "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
identifier[0].system "https://www.upmchealthplan.com/fhir/EOBIdentifier"
identifier[0].value OutpatientEOBExample1
status "active"
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.coding[0].code #institutional
type.text "Institutional"
subType.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"
subType.coding[0].code #outpatient
subType.text "Outpatient"
use "claim"
patient.reference "Patient/ExamplePatient1"
billablePeriod.start "2020-09-29"
billablePeriod.end "2020-09-29"
created "2020-10-10T00:00:00-04:00"
insurer.reference "Organization/PayerOrganizationExample1"
insurer.display "UPMC Health Plan"
provider.reference "Organization/ProviderOrganization5"
payee.type.coding[0].system "http://terminology.hl7.org/CodeSystem/payeetype"
payee.type.coding[0].code #provider
payee.type.coding[0].display "Provider"
payee.type.text "Any benefit payable will be paid to the provider (Assignment of Benefit)."
payee.party.reference "Organization/ProviderOrganization6"
outcome "complete"
careTeam[0].sequence 1
careTeam[0].provider.reference "Practitioner/Practitioner1"
careTeam[0].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[0].role.coding[0].code #attending
careTeam[0].role.coding[0].display "Attending"
careTeam[0].role.text "The attending physician"
careTeam[1].sequence 2
careTeam[1].provider.reference "Practitioner/Practitioner3"
careTeam[1].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[1].role.coding[0].code #referring
careTeam[1].role.coding[0].display "Referring"
careTeam[1].role.text "The referring physician"
supportingInfo[0].sequence 1
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].category.coding[0].display "Billing Network Contracting Status"
supportingInfo[0].category.text "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[0].code.coding[0].display "Contracted"
supportingInfo[0].code.text "Indicates the provider was contracted for the service"
supportingInfo[1].sequence 2
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].category.coding[0].code #clmrecvddate
supportingInfo[1].category.coding[0].display "Claim Received Date"
supportingInfo[1].category.text "Date the claim was received by the payer."
supportingInfo[1].timingDate "2020-10-10"
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #I95.1
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].type[0].coding[0].code #principal
diagnosis[0].type[0].coding[0].display "Principal Diagnosis"
diagnosis[0].type[0].text "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
diagnosis[1].sequence 2
diagnosis[1].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[1].diagnosisCodeableConcept.coding[0].code #I95.1
diagnosis[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[1].type[0].coding[0].code #other
diagnosis[1].type[0].coding[0].display "Other"
diagnosis[1].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[2].sequence 3
diagnosis[2].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[2].diagnosisCodeableConcept.coding[0].code #L97.529
diagnosis[2].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[2].type[0].coding[0].code #other
diagnosis[2].type[0].coding[0].display "Other"
diagnosis[2].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[3].sequence 4
diagnosis[3].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[3].diagnosisCodeableConcept.coding[0].code #I73.9
diagnosis[3].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[3].type[0].coding[0].code #other
diagnosis[3].type[0].coding[0].display "Other"
diagnosis[3].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageEx1"
item[0].sequence 1
item[0].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[0].revenue.coding[0].code #0551
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].code #99231
item[0].servicedDate "2020-09-29"
item[0].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[0].locationCodeableConcept.coding[0].code #12
item[0].locationCodeableConcept.text "HOME"
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].display "Submitted Amount"
item[0].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[0].adjudication[0].amount.value 84.4
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[1].category.coding[0].code #copay
item[0].adjudication[1].category.coding[0].display "CoPay"
item[0].adjudication[1].category.text "Patient Co-Payment"
item[0].adjudication[1].amount.value 0.0
item[0].adjudication[1].amount.currency #USD
item[0].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[2].category.coding[0].code #eligible
item[0].adjudication[2].category.coding[0].display "Eligible Amount"
item[0].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[0].adjudication[2].amount.value 56.52
item[0].adjudication[2].amount.currency #USD
item[0].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[3].category.coding[0].code #deductible
item[0].adjudication[3].category.coding[0].display "Deductible"
item[0].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[0].adjudication[3].amount.value 0.0
item[0].adjudication[3].amount.currency #USD
item[0].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[4].category.coding[0].code #benefit
item[0].adjudication[4].category.coding[0].display "Benefit Amount"
item[0].adjudication[4].category.text "Amount payable under the coverage"
item[0].adjudication[4].amount.value 56.52
item[0].adjudication[4].amount.currency #USD
item[0].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[5].category.coding[0].code #noncovered
item[0].adjudication[5].category.coding[0].display "Noncovered"
item[0].adjudication[5].category.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[0].adjudication[5].amount.value 0.0
item[0].adjudication[5].amount.currency #USD
item[1].sequence 2
item[1].revenue.coding[0].system "https://www.nubc.org/CodeSystem/RevenueCodes"
item[1].revenue.coding[0].code #0023
item[1].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[1].productOrService.coding[0].code #99231
item[1].servicedDate "2020-09-29"
item[1].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[1].locationCodeableConcept.coding[0].code #12
item[1].locationCodeableConcept.text "HOME"
item[1].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[0].category.coding[0].code #submitted
item[1].adjudication[0].category.coding[0].display "Submitted Amount"
item[1].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[1].adjudication[0].amount.value 0.0
item[1].adjudication[0].amount.currency #USD
item[1].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[1].category.coding[0].code #copay
item[1].adjudication[1].category.coding[0].display "CoPay"
item[1].adjudication[1].category.text "Patient Co-Payment"
item[1].adjudication[1].amount.value 0.0
item[1].adjudication[1].amount.currency #USD
item[1].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[2].category.coding[0].code #eligible
item[1].adjudication[2].category.coding[0].display "Eligible Amount"
item[1].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[1].adjudication[2].amount.value 0.0
item[1].adjudication[2].amount.currency #USD
item[1].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[3].category.coding[0].code #deductible
item[1].adjudication[3].category.coding[0].display "Deductible"
item[1].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[1].adjudication[3].amount.value 0.0
item[1].adjudication[3].amount.currency #USD
item[1].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[4].category.coding[0].code #benefit
item[1].adjudication[4].category.coding[0].display "Benefit Amount"
item[1].adjudication[4].category.text "Amount payable under the coverage"
item[1].adjudication[4].amount.value 0.0
item[1].adjudication[4].amount.currency #USD
item[1].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[1].adjudication[5].category.coding[0].code #noncovered
item[1].adjudication[5].category.coding[0].display "Noncovered"
item[1].adjudication[5].category.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[1].adjudication[5].amount.value 0.0
item[1].adjudication[5].amount.currency #USD
total[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[0].category.coding[0].code #submitted
total[0].category.coding[0].display "Submitted Amount"
total[0].category.text "The total submitted amount for the claim or group or line item."
total[0].amount.value 84.4
total[0].amount.currency #USD
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.coding[0].code #eligible
total[1].category.coding[0].display "Eligible Amount"
total[1].category.text "Amount of the change which is considered for adjudication."
total[1].amount.value 56.52
total[1].amount.currency #USD
total[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[2].category.coding[0].code #deductible
total[2].category.coding[0].display "Deductible"
total[2].category.text "Amount deducted from the eligible amount prior to adjudication."
total[2].amount.value 0.0
total[2].amount.currency #USD
total[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[3].category.coding[0].code #copay
total[3].category.coding[0].display "CoPay"
total[3].category.text "Patient Co-Payment"
total[3].amount.value 0.0
total[3].amount.currency #USD
total[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[4].category.coding[0].code #noncovered
total[4].category.coding[0].display "Noncovered"
total[4].category.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[4].amount.value 0.0
total[4].amount.currency #USD
total[5].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[5].category.coding[0].code #benefit
total[5].category.coding[0].display "Benefit Amount"
total[5].category.text "Amount payable under the coverage"
total[5].amount.value 56.52
total[5].amount.currency #USD
total[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[6].category.coding[0].code #memberliability
total[6].category.coding[0].display "Member liability"
total[6].category.text "The amount of the member's liability."
total[6].amount.value 0.0
total[6].amount.currency #USD
total[7].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
total[7].category.coding[0].code #outofnetwork
total[7].amount.value 0.0
total[7].amount.currency #USD