This page is part of a downloaded copy of this specification. This page is part of the CARIN Blue Button Implementation Guide (v0.1.0: STU1 Ballot 1) based on FHIR R4. For a full list of available versions, see the Directory of published versions
Data Element Index
[Previous Page](Mapping_from_CPCDS_to_FHIR_Resources.html)Map ID | CARIN CPCDS Data Element Name | CARIN CPCDS Description | CARIN BB2.0 FHIR Profile | Date Harmonized | FHIR Resource L0 | FHIR Resource L1 Element | FHIR Resource L2 Element | FHIR Element Description or L3 | L4 |
FHIR REF |
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1 | Member id | Unique identifier for a member | Coverage | Coverage | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
1 | Member id | Unique identifier for a member | EOB Inpatient Facility | ExplanationOfBenefit[1] | patient--> | The recipient of the products and services | Reference(Patient) | |||
1 | Member id | Unique identifier for a member | EOB Outpatient Facility | ExplanationOfBenefit | patient--> | The recipient of the products and services | Reference(Patient) | |||
1 | Member id | Unique identifier for a member | EOB Professional | Non-Physician | ExplanationOfBenefit | patient--> | The recipient of the products and services | Reference(Patient) | |||
1 | Member id | Unique identifier for a member | EOB Pharmacy | ExplanationOfBenefit | patient--> | The recipient of the products and services | Reference(Patient) | |||
2 | Payer Identifier | Issuer of the Policy | Coverage | Coverage | payor--> | Issuer of the policy | Reference(Organization) | |||
2 | Claim payer Identifier | Code of the primary payer responsible for the claim | EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
2 | Claim payer Identifier | Code of the primary payer responsible for the claim | EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
2 | Claim payer Identifier | Code of the primary payer responsible for the claim | EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
2 | Claim payer Identifier | Code of the primary payer responsible for the claim | EOB Pharmacy | 7/2/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
3 | Coverage type | Identifies if the coverage is PPO, HMO, POS, etc. | Coverage | Coverage | type | Coverage Type and Self-Pay Codes (Preferred) | ||||
6 | Diagnosis code - ICD-9 admitting | ICD-9-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. (UB04 Form Locator 69). Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
6 | Diagnosis code - ICD-9 admitting | ICD-9-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. (UB04 Form Locator 69). Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
7 | Diagnosis code - ICD-9 principal | The member's principal condition treated during this service. (UB04 Form Locator 67). This may or may not be different from the admitting diagnosis. Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
7 | Diagnosis code - ICD-9 principal | The member's principal condition treated during this service. (UB04 Form Locator 67). This may or may not be different from the admitting diagnosis. Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
7 | Diagnosis code - ICD-9 principal | The member's principal condition treated during this service. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
8 | Diagnosis code - ICD-9 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
8 | Diagnosis code - ICD-9 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
8 | Diagnosis code - ICD-9 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
9 | Procedure Code - ICD-9 PCS principal | Principal medical procedure a patient received during inpatient stay. Current coding methods include: International Classification of Diseases Surgical Procedures (ICD-9). Information located on UB04 (Form Locator 74). | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | Specific clinical procedure | |||
10 | Procedure Date - ICD-9 principal | Date of Procedure. Information located on UB04 (Form Locator 74). | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | When the procedure was performed | |||
11 | Procedure Code - ICD-10 PCS secondary | Additional surgical procedure surgical (ICD-9) administered during inpatient stay. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | Specific clinical procedure | |||
12 | Procedure Date - ICD-9 secondary | Date of Procedure. (UB04 Form Locator 74). | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | When the procedure was performed | |||
13 | Claim source inpatient admission code | The source of admission identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
13 | Claim source inpatient admission code | The source of admission identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
14 | Claim inpatient admission type code | Priority of the inpatient admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
14 | Claim inpatient admission type code | Priority of the inpatient admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
15 | Claim sub type | High-level categorization of the claim. | Removed from scope | Removed from scope | ExplanationOfBenefit | subtype | More granular claim type | |||
15 | Claim sub type | High-level categorization of the claim. | Removed from scope | Removed from scope | ExplanationOfBenefit | subtype | More granular claim type | |||
15 | Claim sub type | High-level categorization of the claim. | Removed from scope | Removed from scope | ExplanationOfBenefit | subtype | More granular claim type | |||
15 | Claim sub type | High-level categorization of the claim. | Removed from scope | Removed from scope | ExplanationOfBenefit | subtype | More granular claim type | |||
16 | Claim type | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | type | Category or discipline | |||
16 | Claim type | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | type | Category or discipline | |||
16 | Claim type | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | type | Category or discipline | |||
16 | Claim type | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). | EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | type | Category or discipline | |||
18 | Member admission date | Identifies the date the patient was admitted for facility care | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | billablePeriod | period.start period.end |
Relevant time frame for the claim | ||
18 | Member admission date | Identifies the date the patient was admitted for facility care | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | billablePeriod | period.start period.end |
Relevant time frame for the claim | ||
19 | Member discharge date |
Date patient was discharged from a facility. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | billablePeriod | period.start period.end |
Relevant time frame for the claim | ||
19 | Member discharge date |
Date patient was discharged from a facility. | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | billablePeriod | period.start period.end |
Relevant time frame for the claim | ||
20 | Claim total submitted
amount |
Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line submitted amount | Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim total submitted
amount |
Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line submitted amount | Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line submitted amount | Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line submitted amount | Represents the Usual & Customary Charge Amount or the Average Wholesale Price (AWP) for the Quantity Dispensed plus the Dispensing Fee Paid. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim total allowed
amount |
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line allowed amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim total allowed
amount |
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line allowed amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line allowed amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line allowed amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed mount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member paid deductible |
The portion of this service that
the member must pay which is applied to the total period deductible. Deductibles are usually applied over a specific time period, such as per calendar year, per benefit period, |
EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line patient deductible |
The portion of this service that
the member must pay which is applied to the total period deductible. Deductibles are usually applied over a specific time period, such as per calendar year, per benefit period, |
EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member paid deductible |
The portion of this service that
the member must pay which is applied to the total period deductible. Deductibles are usually applied over a specific time period, such as per calendar year, per benefit period, |
EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line patient deductible |
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line patient deductible |
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line patient deductible |
The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Co-insurance liability
amount |
The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line coinsurance amount |
The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Co-insurance liability
amount |
The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line coinsurance amount |
The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line coinsurance amount |
The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line coinsurance amount |
Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Copay amount |
Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line copay amount |
Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Copay amount |
Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line copay amount |
Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line copay amount |
Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line copay amount |
Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim disallowed amount |
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. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line disallowed charged
amount |
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. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim disallowed amount |
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. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line disallowed charged
amount |
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. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line disallowed charged
amount |
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. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line disallowed charged
amount |
Non-Covered Amount represents the NCPDP financial response field Amount Exceeding Periodic Benefit Maximum. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line primary payer paid amount | The reduction in the payment amount to reflect the carrier as a secondary payor. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line payment
amount |
The amount sent to the payee from the health plan. This amount is to include withhold amounts (the portion of the claim that is deducted and withheld by the Plan from the provider's payment) and exclude any member cost sharing. It should include the total of member and provider payments. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Amount paid by patient | The amount paid by the member at the point of service. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line amount paid by patient | The amount paid by the member at the point of service. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Amount paid by patient | The amount paid by the member at the point of service. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line amount paid by patient | The amount paid by the member at the point of service. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line amount paid by patient | The amount paid by the member at the point of service. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line amount paid by patient | Amount that is calculated by the processor and returned to the pharmacy as the total amount to be paid by the patient to the pharmacy; the patients total cost share, including copayments, amounts applied to deductible, over maximum amounts, penalties, etc | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim amount paid to
provider |
The amount paid to the provider. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line amount paid to
provider |
The amount paid to the provider. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Claim amount paid to
provider |
The amount paid to the provider. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line amount paid to
provider |
The amount paid to the provider. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line amount paid to
provider |
The amount paid to the provider. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line amount paid to
provider |
The amount paid to the provider. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member reimbursement | The amount paid to the member. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line member reimbursemen | The amount paid to the member. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member reimbursement | The amount paid to the member. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line member reimbursemen | The amount paid to the member. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line member reimbursemen | The amount paid to the member. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line member reimbursemen | The amount paid to the member. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member liability | The amount of the member's liability. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line member liability | The amount of the member's liability. | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Member liability | The amount of the member's liability. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | adjudication | amount | Monetary amount | ||
20 | Line member liability | The amount of the member's liability. | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line member liability | The amount of the member's liability. | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
20 | Line member liability | The amount of the member's liability. | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | item | adjudication | amount | ||
21 | Diagnosis code - ICD-10 admitting | ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
21 | Diagnosis code - ICD-10 admitting | ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
22 | Diagnosis code - ICD-10 principal | The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
22 | Diagnosis code - ICD-10 principal | The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
22 | Diagnosis code - ICD-10 header principal | The member's principal condition treated on the claim (837P Data Element HI01 or CMS 1500 Item 21A). Decimals will be included. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
22 | Diagnosis code - ICD-10 principal | The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
23 | Diagnosis code - ICD-10 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
23 | Diagnosis code - ICD-10 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
23 | Diagnosis code - ICD-10 header secondary | Additional diagnosis identified for this member (837P Data Element HI02 or CMS 1500 Item 21B). Decimals will be included. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
23 | Diagnosis code - ICD-10 secondary | Additional diagnosis identified for this member. Decimals will be included. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
24 | Procedure Code - ICD-10 PCS primary | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | Specific clinical procedure | |||
25 | Procedure Date - ICD-10 primary | Date of Procedure - Principal | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | When the procedure was performed | |||
26 | Procedure Code - ICD-10 PCS secondary | Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | Specific clinical procedure | |||
27 | Procedure Date - ICD-10 secondary | Date of Procedure - Secondary | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | procedure | When the procedure was performed | |||
28 | Present on admission | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | onAdmission | Present on admission | ||
29 | Present on admission | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | onAdmission | Present on admission | ||
30 | Is E code | This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*. | EOB Inpatient Facility | 7/24/2019 | ExplanationOfBenefit | diagnosis | ICD-10 Codes (Example) | |||
30 | Is E code | This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*. | EOB Outpatient Facility | 7/24/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
31 | Patient reason for visit | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. | EOB Inpatient Facility | 7/24/2019 | ExplanationOfBenefit | diagnosis | ICD-10 Codes (Example) | |||
31 | Patient reason for visit | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. | EOB Outpatient Facility | 7/24/2019 | ExplanationOfBenefit | diagnosis | Nature of illness or problem | |||
32 | Claim diagnosis related group (DRG) | Version of the AP-DRG codes assigned for inpatient facility claims. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Classification of the supplied information | ||
33 | Claim diagnosis related group (DRG) | DRG codes assigned | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Classification of the supplied information | ||
34 | Type of service | High level classification of services into logical groupings | EOB Inpatient Facility | 7/24/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
34 | Type of service | High level classification of services into logical groupings | EOB Outpatient Facility | 7/24/2019 | ExplanationOfBenefit | item | category | Benefit classification | ||
34 | Type of service | High level classification of services into logical groupings | EOB Professional | Non-Physician | 7/24/2019 | ExplanationOfBenefit | item | category | Benefit classification | ||
34 | Type of service | High level classification of services into logical groupings | EOB Pharmacy | 7/24/2019 | ExplanationOfBenefit | item | category | category | ||
35 | Claim unique identifier | Claim identifier for a claim. | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | identifier | Business Identifier for the resource | |||
35 | Claim unique identifier | Claim identifier for a claim. | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | identifier | Business Identifier for the resource | |||
35 | Claim unique identifier | Claim identifier for a claim. | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | identifier | Business Identifier for the resource | |||
35 | RX service reference
number |
Assigned by the pharmacy at the
time the prescription is filled |
EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | identifier | Business Identifier for the resource | |||
36 | Line number | Line identification number that represents the number assigned in a source system for identification and processing. | EOB Inpatient Facility | 7/23/2019 | ExplanationOfBenefit | item | sequence | Item instance identifier | ||
36 | Line number | Line identification number that represents the number assigned in a source system for identification and processing. | EOB Outpatient Facility | 7/23/2019 | ExplanationOfBenefit | item | sequence | Item instance identifier | ||
36 | Line number | Line identification number that represents the number assigned in a source system for identification and processing. | EOB Professional | Non-Physician | 7/23/2019 | ExplanationOfBenefit | item | sequence | Item instance identifier | ||
36 | Line number | Line identification number that represents the number assigned in a source system for identification and processing. | EOB Pharmacy | 7/23/2019 | ExplanationOfBenefit | item | sequence | Item instance identifier | ||
38 | National drug code | National Drug Code (NDC) | EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
39 | Quantity dispensed | Quantity dispensed for the drug | EOB Pharmacy | ExplanationOfBenefit | item | quantity | Count of products or services | |||
40 | Procedure Code - CPT / HCPCS | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
40 | Procedure Code - CPT / HCPCS | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
41 | Procedure Code Modifier - CPT / HCPCS | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | item | modifier | Product or service billing modifiers | ||
41 | Procedure Code Modifier - CPT / HCPCS | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | item | modifier | Product or service billing modifiers | ||
42 | Number of units | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. | EOB Inpatient Facility | ExplanationOfBenefit | item | quantity | Count of products or services | |||
42 | Number of units | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. | EOB Outpatient Facility | ExplanationOfBenefit | item | quantity | Count of products or services | |||
42 | Number of units | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. | EOB Professional | Non-Physician | ExplanationOfBenefit | item | quantity | Count of products or services | |||
46 | Place of service code | Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. | EOB Inpatient Facility | ExplanationOfBenefit | supportingInfo | code | Type of information | |||
46 | Place of service code | Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. | EOB Outpatient Facility | ExplanationOfBenefit | supportingInfo | code | Type of information | |||
46 | Place of service code | Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. | EOB Professional | Non-Physician | ExplanationOfBenefit | item | location | Place of service or where product was supplied | |||
70 | Date of birth | Date of birth of the member | Coverage | Coverage | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
71 | Gender code | Gender of the member | Coverage | Coverage | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
72 | Relationship to subscriber | Relationship of the member to the person insured (subscriber). | Coverage | Coverage | relationship | Beneficiary relationship to the subscriber | ||||
74 | Start date | Date that the contract became effective | Coverage | Coverage | period | Coverage start and end dates | ||||
75 | End date | Date that the contract was terminated or coverage changed | Coverage | Coverage | period | Coverage start and end dates | ||||
77 | Days supply | Number of days supply of medication dispensed by the pharmacy | EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | supportingInfo | value | Quantity | ||
78 | Compound code | The code indicating whether or not the prescription is a compound | EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
79 | DAW product selection code | Prescriber's instruction
regarding substitution of generic equivalents or order to dispense the
specific prescribed medication |
EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | supportingInfo | code | CodeableConcept | ||
80 | Removed from scope | Removed from scope | Removed from scope | Removed from scope | ExplanationOfBenefit | supportingInfo | code | CodeableConcept | ||
85 | Removed from scope | Removed from scope | Removed from scope | Removed from scope | ||||||
86 | Revenue center code | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed | EOB Inpatient Facility | ExplanationOfBenefit | item | revenue | Revenue or cost center code | |||
86 | Revenue center code | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed | EOB Outpatient Facility | ExplanationOfBenefit | item | revenue | Revenue or cost center code | |||
88 | Claim received date | The date the claim for payment was received | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | supportingInfo | timing | timing | date | ||
88 | Claim received date | The date the claim for payment was received | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | supportingInfo | timing | timing | date | ||
88 | Claim received date | The date the claim for payment was received | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | supportingInfo | timing | timing | date | ||
88 | Claim received date | The date the claim for payment was received | EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | supportingInfo | timing | timing | date | ||
90 | Service (from) date | Date on which services
began. UB04 (Form Locator 45). |
EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | item | serviced | Date or dates of service or product delivery | ||
90 | Service (from) date | Identifies date the prescription
was filled or professional service rendered |
EOB Pharmacy | 6/28/2019 | ExplanationOfBenefit | item | serviced | Date or dates of service or product delivery | ||
91 | Claim payment status code | Indicates whether the line was paid or denied. | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | payment | type | Partial or complete payment | ||
91 | Claim payment status code | Indicates whether the line was paid or denied. | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | payment | type | Partial or complete payment | ||
91 | Claim payment status code | Indicates whether the line was paid or denied. | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | payment | type | Partial or complete payment | ||
91 | Claim payment status code | Indicates whether the line was paid or denied. | EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | payment | type | Partial or complete payment | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | payment | adjustmentReason | Explanation for the variance | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | item | adjudication | Explanation of adjudication outcome | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | payment | adjustmentReason | Explanation for the variance | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | item | adjudication | Explanation of adjudication outcome | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | item | adjudication | Explanation of adjudication outcome | ||
92 | Claim Payment Denial Code | Reason codes used to interpret the Non-Covered Amount | EOB Pharmacy | 7/8/2019 | ExplanationOfBenefit | item | adjudication | Explanation of adjudication outcome | ||
93 | Claim attending provider NPI | The National Provider Identifier assigned to the Attending Physician for the admission | EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
94 | Claim billing provider NPI | The National Provider Identifier assigned to the Billing Provider. | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | provider--> | Party responsible for the claim | Reference(Organization) | ||
94 | Claim billing provider NPI | The National Provider Identifier assigned to the Billing Provider. | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | provider--> | Party responsible for the claim | Reference(Organization) | ||
94 | Claim billing provider NPI | The National Provider Identifier assigned to the Billing Provider. | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | provider--> | Party responsible for the claim | Reference(Organization) | ||
94 | Claim billing provider NPI | The National Provider Identifier assigned to the Billing Provider. | EOB Pharmacy | 7/8/2019 | ExplanationOfBenefit | provider--> | Party responsible for the claim | Reference(Organization) | ||
95 | Claim performing physician NPI | The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). | EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
95 | Claim performing physician NPI | The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). | EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
95 | Claim performing physician NPI | The National Provider Identifier assigned to the Rendering Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). | EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
96 | Claim PCP NPI | The identifier assigned to the PCP Provider. | EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
96 | Claim PCP NPI | The identifier assigned to the PCP Provider. | EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
96 | Claim PCP NPI | The identifier assigned to the PCP Provider. | EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
95 | Claim PCP NPI | The identifier assigned to the PCP Provider. | EOB Pharmacy | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
97 | Claim site of service NPI | The NPI of the facility where the services were rendered. | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | facility--> | Servicing Facility | Reference(Location) | ||
99 | Claim Referring Physician NPI | The NPI of the referring physician. | EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
99 | Claim Referring Physician NPI | The NPI of the referring physician. | EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
99 | Claim Referring Physician NPI | The NPI of the referring physician. | EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
101 | Claim billing provider network status | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim billing provider network status | Indicates that the Rendering Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim billing provider network status | Indicates that the Rendering
Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. |
EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim billing provider network status | Indicates that the Rendering
Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. |
EOB Pharmacy | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim performing physician network status | Indicates that the Rendering
Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. |
EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim attending provider network status | Indicates the network status of the attending physician | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim Referring Physican Network Status | Indicates the network status of the referring physician | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim Referring Physican Network Status | Indicates the network status of the referring physician | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim Referring Physican Network Status | Indicates the network status of the referring physician | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
101 | Claim site of service network
status |
Indicates the network status of the site of service | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
107 | Claim paid date | The date the claim was paid. | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | payment | date | Expected date of payment | ||
107 | Claim paid date | The date the claim was paid. | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | payment | date | Expected date of payment | ||
107 | Claim paid date | The date the claim was paid. | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | payment | date | Expected date of payment | ||
107 | Claim paid date | The date the claim was paid. | EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | payment | date | Expected date of payment | ||
109 | Patient account number | Provider submitted information that can be included on the claim | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
109 | Patient account number | Provider submitted information that can be included on the claim | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
109 | Patient account number | Provider submitted information that can be included on the claim | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
110 | Medical record number | Provider submitted information that can be included on the claim | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
110 | Medical record number | Provider submitted information that can be included on the claim | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
110 | Medical record number | Provider submitted information that can be included on the claim | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | patient--> | The recipient of the products and services | identifier | ||
111 | Claim adjusted from identifier | Prior claim number | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
111 | Claim adjusted from identifier | Prior claim number | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
111 | Claim adjusted from identifier | Prior claim number | EOB Professional | Non-Physician | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
111 | Claim adjusted from identifier | Prior claim number | EOB Pharmacy | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
112 | Claim adjusted to identifier | Replaced or Merged claim number | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
112 | Claim adjusted to identifier | Replaced or Merged claim number | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
112 | Claim adjusted to identifier | Replaced or Merged claim number | EOB Professional | Non-Physician | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
112 | Claim adjusted to identifier | Replaced or Merged claim number | EOB Pharmacy | 6/28/2019 | ExplanationOfBenefit | related | Prior or corollary claims | |||
113 | Claim diagnosis related group (DRG) | Name of the DRG grouper assigned | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Classification of the supplied information | ||
114 | Claim bill facility type code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
114 | Claim bill facility type code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility. | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
115 | Claim service classification type code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The second digit classifies the type of care (service classification) being billed. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
115 | Claim service classification type code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The second digit classifies the type of care (service classification) being billed. | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
116 | Claim frequency code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
116 | Claim frequency code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
117 | Patient discharge status code | Patients status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). | EOB Inpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
117 | Patient discharge status code | Patients status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). | EOB Outpatient Facility | 6/28/2019 | ExplanationOfBenefit | supportingInfo | code | Type of information | ||
118 | Service (from) date | Date on which services began.
Located on CMS 1500 (Form Locator 24A) |
EOB Professional | Non-Physician | 6/28/2019 | ExplanationOfBenefit | item | servicedPeriod | Relevant time frame for the line | ||
119 | Service to date | Date on which services ended.
Located on CMS 1500 (Form Locator 24A) |
EOB Professional | Non-Physician | 6/28/2019 | ExplanationOfBenefit | item | servicedPeriod | Relevant time frame for the line | ||
120 | Claim payee type code | Identifies recipient of benefits
payable; i.e., provider or subscriber |
EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | payee | type | Category of recipient | ||
120 | Claim payee type code | Identifies recipient of benefits
payable; i.e., provider or subscriber |
EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | payee | type | Category of recipient | ||
120 | Claim payee type code | Identifies recipient of benefits
payable; i.e., provider or subscriber |
EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | payee | type | Category of recipient | ||
120 | Claim payee type code | Identifies recipient of benefits
payable; i.e., provider or subscriber |
EOB Pharmacy | 7/2/2019 | ExplanationOfBenefit | payee | type | Category of recipient | ||
121 | Claim payee | Recipient reference |
EOB Inpatient Facility | 7/2/2019 | ExplanationOfBenefit | payee | party--> | Recipient reference | Reference(PractitionerRole | Patient) | |
121 | Claim payee | Recipient reference |
EOB Outpatient Facility | 7/2/2019 | ExplanationOfBenefit | payee | party--> | Recipient reference | Reference(PractitionerRole | Patient) | |
121 | Claim payee | Recipient reference |
EOB Professional | Non-Physician | 7/2/2019 | ExplanationOfBenefit | payee | party--> | Recipient reference | Reference(PractitionerRole | Patient) | |
121 | Claim payee | Recipient reference |
EOB Pharmacy | 7/2/2019 | ExplanationOfBenefit | payee | party--> | Recipient reference | Reference(PractitionerRole | Patient) | |
122 | Claim prescribing physician NPI | The identifier from NCPDP field # 411-DB (Prescriber ID) that identifies the National Provider Identifier (NPI) of the provider who prescribed the pharmaceutical. | EOB Pharmacy | 7/8/2019 | ExplanationOfBenefit | careTeam | provider--> | Practitioner or organization | Reference(Practitioner | PractitionerRole | Organization) | |
123 | Claim prescriber Network Status | Indicates the network status of the prescribing physician | EOB Pharmacy | |||||||
124 | Date of death | Date of death of the member | Coverage | Coverage[2] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
125 | County | The county for the member's primary address | Coverage | Coverage[3] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
126 | State | The state for the member's primary address | Coverage | Coverage[4] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
127 | Country | The country for the member's primary address | Coverage | Coverage[5] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
128 | Race Code | The race of the member | Coverage | Coverage[6] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
129 | Ethnicity | The ethnicity of the member | Coverage | Coverage[7] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
130 | Patient Name | The name of the patient | Coverage | Coverage[8] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
131 | ZIP Code | This represents the member's 5 digit zip code | Coverage | Coverage[9] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
132 | Subscriber id | Identifies the subscriber identification | Coverage | Coverage[10] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
133 | Coverage status | Identfies the member's coverage status | Coverage | Coverage[11] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
134 | Group id | Employer account identifier | Coverage | Coverage[12] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
135 | Group name | Name of the Employer Account | Coverage | Coverage[13] | beneficiary--> | Plan beneficiary | Reference(Patient) | |||
137 | Refill number | The number fill of the current
dispensed supply (0, 1, 2, etc.) |
EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | supportingInfo | value | Quantity | ||
140 | Claim processing status
code |
EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | status | active | cancelled | draft | entered-in-error | ||||
140 | Claim processing status
code |
EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | status | active | cancelled | draft | entered-in-error | ||||
140 | Claim processing status
code |
EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | status | active | cancelled | draft | entered-in-error | ||||
140 | Claim processing status
code |
EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | status | active | cancelled | draft | entered-in-error | ||||
141 | Claim primary payer identifier | Identifies the primary payer. For use only on secondary claims. | EOB Inpatient Facility | 7/1/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
141 | Claim primary payer identifier | Identifies the primary payer. For use only on secondary claims. | EOB Outpatient Facility | 7/1/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
141 | Claim primary payer identifier | Identifies the primary payer. For use only on secondary claims. | EOB Professional | Non-Physician | 7/1/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
141 | Claim primary payer identifier | Identifies the primary payer. For use only on secondary claims. | EOB Pharmacy | 7/1/2019 | ExplanationOfBenefit | insurance | Insurance information | Reference(Coverage) | ||
142 | Line benefit payment status | Indicates the in network or out of network payment status of the claim. | EOB Inpatient Facility | 7/8/2019 | ExplanationOfBenefit | adjudication | category | Type of adjudication information | ||
142 | Line benefit payment status | Indicates the in network or out of network payment status of the claim. | EOB Outpatient Facility | 7/8/2019 | ExplanationOfBenefit | adjudication | category | Type of adjudication information | ||
142 | Line benefit payment status | Indicates the in network or out of network payment status of the claim. | EOB Professional | Non-Physician | 7/8/2019 | ExplanationOfBenefit | item | adjudication | CodeableConcept | ||
142 | Line benefit payment status | Indicates the in network or out of network payment status of the claim. | EOB Pharmacy | 7/8/2019 | ExplanationOfBenefit | item | adjudication | CodeableConcept | ||
143 | Prescription origin code | Whether the prescription was
transmitted as an electronic prescription, by phone, by fax, or as a written
paper copy |
EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | supportingInfo | code | CodeableConcept | ||
144 | Plan reported brand-generic code | Whether the plan adjudicated the
claim as a brand or generic drug |
EOB Pharmacy | 7/17/2019 | ExplanationOfBenefit | supportingInfo | code | CodeableConcept | ||
145 | Diagnosis Code Description | A plain text representation of the diagnosis | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | diagnosis | CodeableConcept | ||
145 | Diagnosis Code Description | A plain text representation of the diagnosis | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | diagnosis | CodeableConcept | ||
145 | Diagnosis Code Description | A plain text representation of the diagnosis | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | diagnosis | diagnosis | CodeableConcept | ||
146 | ICD Procedure Code Description | A plain text representation of the ICD procedure | EOB Inpatient Facility | 7/19/2019 | ExplanationOfBenefit | diagnosis | diagnosis | CodeableConcept | ||
147 | CPT / HCPCS Procedure Code Description | A plain text representation of the CPT / HCPCS procedure | EOB Outpatient Facility | 7/19/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
147 | CPT / HCPCS Procedure Code Description | A plain text representation of the CPT / HCPCS procedure | EOB Professional | Non-Physician | 7/19/2019 | ExplanationOfBenefit | item | productOrService | Billing, service, product, or drug code | ||
148 | Total Amount | Total amount for each category (i.e., submitted, allowed, etc.) | EOB Inpatient Facility | 7/26/2019 | ExplanationOfBenefit | total | amount | Financial total for the category | ||
148 | Total Amount | Total amount for each category (i.e., submitted, allowed, etc.) | EOB Outpatient Facility | 7/26/2019 | ExplanationOfBenefit | total | amount | Financial total for the category | ||
148 | Total Amount | Total amount for each category (i.e., submitted, allowed, etc.) | EOB Professional | Non-Physician | 7/26/2019 | ExplanationOfBenefit | total | amount | Financial total for the category | ||
148 | Total Amount | Total amount for each category (i.e., submitted, allowed, etc.) | EOB Pharmacy | 7/26/2019 | ExplanationOfBenefit | total | amount | Financial total for the category |