EOB Outpatient Institutional - Example 1 - CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) v2.1.0

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Outpatient Institutional - Example 1

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit EOBOutpatient1

Last updated: 2019-12-12 09:14:11+0000; Language: en-US

Profile: C4BB ExplanationOfBenefit Outpatient Institutionalversion: null2.1.0)

identifier: Unique Claim ID/AW123412341234123412341234123412

status: Active

type: Institutional

subType: Outpatient

use: Claim

patient: Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)

billablePeriod: 2019-01-01 --> 2019-10-31

created: 2019-11-02 00:00:00+0000

insurer: Organization Payer 1

provider: Orange Medical Group

outcome: Partial Processing

CareTeams

Sequence

Provider

Role

Qualification

1

Organization Orange Medical Group

Rendering provider

Oncology Clinical Nurse Specialist

supportingInfo
sequence: 2
category: Claim Received Date
timing: 2019-11-30

supportingInfo
sequence: 3
category: Type of Bill
code: Dummy

supportingInfo
sequence: 4
category: Point Of Origin
code: Dummy

supportingInfo
sequence: 5
category: Admission Type
code: Dummy

supportingInfo
sequence: 6
category: Discharge Status
code: Dummy

supportingInfo
sequence: 7
category: Medical Record Number
value: 1234-234-1243-12345678901m

supportingInfo
sequence: 8
category: Patient Account Number
value: 1234-234-1243-12345678901a

Diagnoses

Sequence

Diagnosis[x]

Type

1

Concussion w LOC of 30 minutes or less, init

Patient Reason for Visit

Insurances

Focal

Coverage

true

Coverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --> 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA

Items

Sequence

Revenue

ProductOrService

Serviced[x]

1

Dummy

Not Applicable

2019-11-02

adjudication
category: Benefit Payment Status
reason: In Network

adjudication
category: Billing Network Status
reason: In Network

adjudication
category: Payment Amount
Amounts
- Value Currency
* 620 United States dollar

adjudication
category: Patient Pay Amount
Amounts
- Value
* 0

total
category: Payment Amount
Amounts
- Value Currency
* 620 United States dollar

total
category: Submitted Amount
Amounts
- Value Currency
* 2650 United States dollar

total
category: Patient Pay Amount
Amounts
- Value Currency
* 0 United States dollar

Notes:

Instance: EOBOutpatient1
InstanceOf: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.1.0
Title: "EOB Outpatient Institutional - Example 1"
Description: "EOB Outpatient Institutional - Example 1"
Usage: #example
* meta.lastUpdated = "2019-12-12T09:14:11+00:00"
* language = #en-US
* identifier
  * type = C4BBIdentifierType#uc
  * system = "https://www.xxxplan.com/fhir/EOBIdentifier"
  * value = "AW123412341234123412341234123412"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#institutional
  * text = "Institutional"
* subType = C4BBInstitutionalClaimSubType#outpatient
  * text = "Outpatient"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod
  * start = "2019-01-01"
  * end = "2019-10-31"
* created = "2019-11-02T00:00:00+00:00"
* insurer = Reference(Payer1) "Organization Payer 1"
* provider = Reference(ProviderOrganization1) "Orange Medical Group"
* outcome = #partial
* careTeam
  * sequence = 1
  * provider = Reference(ProviderOrganization1)
  * role = C4BBClaimCareTeamRole#rendering "Rendering provider"
  * qualification = http://nucc.org/provider-taxonomy#364SX0200X "Oncology Clinical Nurse Specialist"
* supportingInfo[0]
  * sequence = 2
  * category = C4BBSupportingInfoType#clmrecvddate
  * timingDate = "2019-11-30"
* supportingInfo[+]
  * sequence = 3
  * category = C4BBSupportingInfoType#typeofbill
  * code = https://www.nubc.org/CodeSystem/TypeOfBill#Dummy
* supportingInfo[+]
  * sequence = 4
  * category = C4BBSupportingInfoType#pointoforigin
  * code = https://www.nubc.org/CodeSystem/PointOfOrigin#Dummy
* supportingInfo[+]
  * sequence = 5
  * category = C4BBSupportingInfoType#admtype
  * code = https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit#Dummy
* supportingInfo[+]
  * sequence = 6
  * category = C4BBSupportingInfoType#discharge-status
  * code = https://www.nubc.org/CodeSystem/PatDischargeStatus#Dummy
* supportingInfo[+]
  * sequence = 7
  * category = C4BBSupportingInfoType#medicalrecordnumber
  * valueString = "1234-234-1243-12345678901m"
* supportingInfo[+]
  * sequence = 8
  * category = C4BBSupportingInfoType#patientaccountnumber
  * valueString = "1234-234-1243-12345678901a"
* diagnosis
  * sequence = 1
  * diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#S06.0X1A
  * type = C4BBClaimDiagnosisType#patientreasonforvisit
* insurance
  * focal = true
  * coverage = Reference(Coverage3)
* item
  * sequence = 1
  * revenue = https://www.nubc.org/CodeSystem/RevenueCodes#Dummy
  * productOrService = http://terminology.hl7.org/CodeSystem/data-absent-reason#not-applicable "Not Applicable"
  * servicedDate = "2019-11-02"
* adjudication[0]
  * category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
  * category = C4BBAdjudicationDiscriminator#billingnetworkstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
  * category = C4BBAdjudication#paidtoprovider
    * text = "Payment Amount"
  * amount
    * value = 620
    * currency = #USD
* adjudication[+]
  * category = C4BBAdjudication#paidbypatient
    * text = "Patient Pay Amount"
  * amount.value = 0
* total[0]
  * category = C4BBAdjudication#paidtoprovider
    * text = "Payment Amount"
  * amount
    * value = 620
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
    * text = "Submitted Amount"
  * amount
    * value = 2650
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#paidbypatient
    * text = "Patient Pay Amount"
  * amount
    * value = 0
    * currency = #USD

IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2025-02-18
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