Publication Build: This will be filled in by the publication tooling
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "EOBOutpatient2"];
fhir:Resource.meta [
fhir:Meta.lastUpdated [ fhir:value "2020-10-13T11:10:24-04:00"^^xsd:dateTime ];
fhir:Meta.source [ fhir:value "Organization/PayerOrganizationExample1" ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0> ]
];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBOutpatient2\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ExplanationOfBenefit "EOBOutpatient2" Updated "2020-10-13 11:10:24-0400" </p><p style=\"margin-bottom: 0px\">Information Source: Organization/PayerOrganizationExample1!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Outpatient-Institutional.html\">C4BB ExplanationOfBenefit Outpatient Institutional (version 2.0.0)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: OutpatientEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>subType</b>: Outpatient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBInstitutionalClaimSubType.html\">C4BB Institutional Claim SubType Code System</a>#outpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Patient/Patient1</a> " EXAMPLE1"</p><p><b>billablePeriod</b>: 2020-09-29 --> 2020-09-29</p><p><b>created</b>: 2020-10-10 12:00:00-0400</p><p><b>insurer</b>: <a href=\"Organization-Payer2.html\">Organization/Payer2: UPMC Health Plan</a> "UPMC Health Plan"</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization5.html\">Organization/ProviderOrganization5</a> "Black Medical Group"</p><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>Any benefit payable will be paid to the provider (Assignment of Benefit). <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html\">Claim Payee Type Codes</a>#provider "Provider")</span></td><td><a href=\"Organization-ProviderOrganization6.html\">Organization/ProviderOrganization6</a> "White Medical Group"</td></tr></table><p><b>outcome</b>: complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner1.html\">Practitioner/Practitioner1</a> " SMITH"</p><p><b>role</b>: The attending physician <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimCareTeamRole.html\">C4BB Claim Care Team Role Code System</a>#attending "Attending")</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner3.html\">Practitioner/Practitioner3</a> " WILLIAMS"</p><p><b>role</b>: The referring physician <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimCareTeamRole.html\">C4BB Claim Care Team Role Code System</a>#referring "Referring")</span></p></blockquote><h3>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td>*</td><td>1</td><td>Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#clmrecvddate)</span></td><td>2020-10-10</td></tr></table><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Orthostatic hypotension <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#I95.1)</span></p><p><b>type</b>: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal "Principal Diagnosis")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Orthostatic hypotension <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#I95.1)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimDiagnosisType.html\">C4BB Claim Diagnosis Type Code System</a>#other "Other")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: Non-pressure chronic ulcer oth prt left foot w unsp severity <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#L97.529)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimDiagnosisType.html\">C4BB Claim Diagnosis Type Code System</a>#other "Other")</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: Peripheral vascular disease, unspecified <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#I73.9)</span></p><p><b>type</b>: Required when other conditions coexist or develop subsequently during the treatment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimDiagnosisType.html\">C4BB Claim Diagnosis Type Code System</a>#other "Other")</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-Coverage1.html\">Coverage/Coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: 0551 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#0551)</span></p><p><b>productOrService</b>: 99231 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2020-09-29</p><p><b>location</b>: HOME <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#12)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted "Submitted Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>84.4</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay "CoPay")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible "Eligible Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>56.52</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible "Deductible")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit "Benefit Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>56.52</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered "Noncovered")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: 0023 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#0023)</span></p><p><b>productOrService</b>: 99231 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#99231)</span></p><p><b>serviced</b>: 2020-09-29</p><p><b>location</b>: HOME <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#12)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted "Submitted Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered "Noncovered")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td>Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible "Eligible Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>56.52</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible "Deductible")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay "CoPay")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: 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. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered "Noncovered")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit "Benefit Amount")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>56.52</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: The amount of the member's liability. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#memberliability "Member liability")</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
];
fhir:ExplanationOfBenefit.identifier [
fhir:index 0;
fhir:Identifier.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" ];
fhir:Coding.code [ fhir:value "uc" ];
fhir:Coding.display [ fhir:value "Unique Claim ID" ] ];
fhir:CodeableConcept.text [ fhir:value "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" ] ];
fhir:Identifier.system [ fhir:value "https://www.upmchealthplan.com/fhir/EOBIdentifier" ];
fhir:Identifier.value [ fhir:value "OutpatientEOBExample1" ]
];
fhir:ExplanationOfBenefit.status [ fhir:value "active"];
fhir:ExplanationOfBenefit.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
fhir:Coding.code [ fhir:value "institutional" ] ];
fhir:CodeableConcept.text [ fhir:value "Institutional" ]
];
fhir:ExplanationOfBenefit.subType [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType" ];
fhir:Coding.code [ fhir:value "outpatient" ] ];
fhir:CodeableConcept.text [ fhir:value "Outpatient" ]
];
fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
fhir:ExplanationOfBenefit.patient [
fhir:Reference.reference [ fhir:value "Patient/Patient1" ]
];
fhir:ExplanationOfBenefit.billablePeriod [
fhir:Period.start [ fhir:value "2020-09-29"^^xsd:date ];
fhir:Period.end [ fhir:value "2020-09-29"^^xsd:date ]
];
fhir:ExplanationOfBenefit.created [ fhir:value "2020-10-10T00:00:00-04:00"^^xsd:dateTime];
fhir:ExplanationOfBenefit.insurer [
fhir:Reference.reference [ fhir:value "Organization/Payer2" ];
fhir:Reference.display [ fhir:value "UPMC Health Plan" ]
];
fhir:ExplanationOfBenefit.provider [
fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization5" ]
];
fhir:ExplanationOfBenefit.payee [
fhir:ExplanationOfBenefit.payee.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
fhir:Coding.code [ fhir:value "provider" ];
fhir:Coding.display [ fhir:value "Provider" ] ];
fhir:CodeableConcept.text [ fhir:value "Any benefit payable will be paid to the provider (Assignment of Benefit)." ] ];
fhir:ExplanationOfBenefit.payee.party [
fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization6" ] ]
];
fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
fhir:ExplanationOfBenefit.careTeam [
fhir:index 0;
fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.careTeam.provider [
fhir:Reference.reference [ fhir:value "Practitioner/Practitioner1" ] ];
fhir:ExplanationOfBenefit.careTeam.role [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" ];
fhir:Coding.code [ fhir:value "attending" ];
fhir:Coding.display [ fhir:value "Attending" ] ];
fhir:CodeableConcept.text [ fhir:value "The attending physician" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.careTeam.provider [
fhir:Reference.reference [ fhir:value "Practitioner/Practitioner3" ] ];
fhir:ExplanationOfBenefit.careTeam.role [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" ];
fhir:Coding.code [ fhir:value "referring" ];
fhir:Coding.display [ fhir:value "Referring" ] ];
fhir:CodeableConcept.text [ fhir:value "The referring physician" ] ]
];
fhir:ExplanationOfBenefit.supportingInfo [
fhir:index 0;
fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
fhir:Coding.code [ fhir:value "clmrecvddate" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.timingDate [ fhir:value "2020-10-10"^^xsd:date ]
];
fhir:ExplanationOfBenefit.diagnosis [
fhir:index 0;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "I95.1" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" ];
fhir:Coding.code [ fhir:value "principal" ];
fhir:Coding.display [ fhir:value "Principal Diagnosis" ] ];
fhir:CodeableConcept.text [ fhir:value "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "I95.1" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "L97.529" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "4"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
fhir:Coding.code [ fhir:value "I73.9" ] ] ];
fhir:ExplanationOfBenefit.diagnosis.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Required when other conditions coexist or develop subsequently during the treatment" ] ]
];
fhir:ExplanationOfBenefit.insurance [
fhir:index 0;
fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
fhir:ExplanationOfBenefit.insurance.coverage [
fhir:Reference.reference [ fhir:value "Coverage/Coverage1" ] ]
];
fhir:ExplanationOfBenefit.item [
fhir:index 0;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.nubc.org/CodeSystem/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0551" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-09-29"^^xsd:date ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "12" ] ];
fhir:CodeableConcept.text [ fhir:value "HOME" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "84.4"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "56.52"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "56.52"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir:value "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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.item.revenue [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.nubc.org/CodeSystem/RevenueCodes" ];
fhir:Coding.code [ fhir:value "0023" ] ] ];
fhir:ExplanationOfBenefit.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "99231" ] ] ];
fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-09-29"^^xsd:date ];
fhir:ExplanationOfBenefit.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
fhir:Coding.code [ fhir:value "12" ] ];
fhir:CodeableConcept.text [ fhir:value "HOME" ] ];
fhir:ExplanationOfBenefit.item.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "submitted" ];
fhir:Coding.display [ fhir:value "Submitted Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ], [
fhir:index 1;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir:value "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." ] ];
fhir:ExplanationOfBenefit.item.adjudication.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ] ]
];
fhir:ExplanationOfBenefit.adjudication [
fhir:index 0;
fhir:ExplanationOfBenefit.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
fhir:Coding.code [ fhir:value "benefitpaymentstatus" ] ] ];
fhir:ExplanationOfBenefit.item.adjudication.reason [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
fhir:Coding.code [ fhir:value "innetwork" ] ] ]
];
fhir:ExplanationOfBenefit.total [
fhir:index 0;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "eligible" ];
fhir:Coding.display [ fhir:value "Eligible Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "56.52"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "deductible" ];
fhir:Coding.display [ fhir:value "Deductible" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "copay" ];
fhir:Coding.display [ fhir:value "CoPay" ] ];
fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "noncovered" ];
fhir:Coding.display [ fhir:value "Noncovered" ] ];
fhir:CodeableConcept.text [ fhir:value "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." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 4;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
fhir:Coding.code [ fhir:value "benefit" ];
fhir:Coding.display [ fhir:value "Benefit Amount" ] ];
fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "56.52"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 5;
fhir:ExplanationOfBenefit.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
fhir:Coding.code [ fhir:value "memberliability" ];
fhir:Coding.display [ fhir:value "Member liability" ] ];
fhir:CodeableConcept.text [ fhir:value "The amount of the member's liability." ] ];
fhir:ExplanationOfBenefit.total.amount [
fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.
IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#2.0.0 based on FHIR 4.0.1. Generated 2022-11-28
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