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 "EOBInpatient2"];
fhir:Resource.meta [
fhir:Meta.lastUpdated [ fhir:value "2020-04-28T15:39:36-04:00"^^xsd:dateTime ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.0";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-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=\"EOBInpatient2\"> </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 "EOBInpatient2" Updated "2020-04-28 03:39:36-0400" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Inpatient-Institutional.html\">C4BB ExplanationOfBenefit Inpatient 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: InpatientEOBExample1</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>: Inpatient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBInstitutionalClaimSubType.html\">C4BB Institutional Claim SubType Code System</a>#inpatient)</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>: 2017-05-23 --> 2017-05-23</p><p><b>created</b>: 2017-06-01 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-ProviderOrganization3.html\">Organization/ProviderOrganization3</a> "Green 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-ProviderOrganization4.html\">Organization/ProviderOrganization4</a> "Blue 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-Practitioner2.html\">Practitioner/Practitioner2</a> " BROWN"</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-Practitioner2.html\">Practitioner/Practitioner2</a> " BROWN"</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><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Admission Period <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#admissionperiod)</span></p><p><b>timing</b>: 2017-05-23 --> (ongoing)</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: 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></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Non-ST elevation (NSTEMI) myocardial infarction <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>#I21.4)</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>: Athscl heart disease of native cor art w oth ang pctrs <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>#I25.118)</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>: Hyperlipidemia, 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>#E78.5)</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>: Unspecified osteoarthritis, unspecified site <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>#M19.90)</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>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimProcedureType.html\">C4BB Claim Procedure Type Code System</a>#principal "Principal")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: 4A023N7 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10PCS.html\">ICD-10 Procedure Codes</a>#4A023N7)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: Other procedures performed during the inpatient institutional admission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimProcedureType.html\">C4BB Claim Procedure Type Code System</a>#other "Other")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: B211YZZ <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10PCS.html\">ICD-10 Procedure Codes</a>#B211YZZ)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: Other procedures performed during the inpatient institutional admission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimProcedureType.html\">C4BB Claim Procedure Type Code System</a>#other "Other")</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: B215YZZ <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10PCS.html\">ICD-10 Procedure Codes</a>#B215YZZ)</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-Coverage2.html\">Coverage/Coverage2</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: 0301 <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>#0301)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: 0260 <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>#0260)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: 0305 <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>#0305)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: 0324 <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>#0324)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: 0259 <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>#0259)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: 0250 <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>#0250)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: 0710 <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>#0710)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: 0210 <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>#0210)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: 0272 <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>#0272)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: 0370 <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>#0370)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: 0730 <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>#0730)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: 0450 <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>#0450)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: 0481 <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>#0481)</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>: 2017-05-23 --> (ongoing)</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <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>#21)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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></p><p><b>reason</b>: Out Of Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#outofnetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></p><p><b>reason</b>: Indicates the provider was in network for the service <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork "In Network")</span></p></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></blockquote><blockquote><p><b>total</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>7147.2</td><td>USD</td></tr></table></blockquote><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>1542.01</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>120</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>1393.57</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 "InpatientEOBExample1" ]
];
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 "inpatient" ] ];
fhir:CodeableConcept.text [ fhir:value "Inpatient" ]
];
fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
fhir:ExplanationOfBenefit.patient [
fhir:Reference.reference [ fhir:value "Patient/Patient1" ]
];
fhir:ExplanationOfBenefit.billablePeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ];
fhir:Period.end [ fhir:value "2017-05-23"^^xsd:date ]
];
fhir:ExplanationOfBenefit.created [ fhir:value "2017-06-01T00:00:00-04:00"^^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/ProviderOrganization3" ]
];
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/ProviderOrganization4" ] ]
];
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/Practitioner2" ] ];
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/Practitioner2" ] ];
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 "2"^^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 "admissionperiod" ] ] ];
fhir:ExplanationOfBenefit.supportingInfo.timingPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^xsd:date ] ]
], [
fhir:index 1;
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 "2017-06-01"^^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 "I21.4" ] ] ];
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 "I25.118" ] ] ];
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 "E78.5" ] ] ];
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 "M19.90" ] ] ];
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.procedure [
fhir:index 0;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "principal" ];
fhir:Coding.display [ fhir:value "Principal" ] ];
fhir:CodeableConcept.text [ fhir:value "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "4A023N7" ] ] ]
], [
fhir:index 1;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Other procedures performed during the inpatient institutional admission" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "B211YZZ" ] ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.procedure.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ExplanationOfBenefit.procedure.type [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType" ];
fhir:Coding.code [ fhir:value "other" ];
fhir:Coding.display [ fhir:value "Other" ] ];
fhir:CodeableConcept.text [ fhir:value "Other procedures performed during the inpatient institutional admission" ] ];
fhir:ExplanationOfBenefit.procedure.date [ fhir:value "2017-05-23"^^xsd:date ];
fhir:ExplanationOfBenefit.procedure.procedureCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/ICD10" ];
fhir:Coding.code [ fhir:value "B215YZZ" ] ] ]
];
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/Coverage2" ] ]
];
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 "0301" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
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 "0260" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 2;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "3"^^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 "0305" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 3;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "4"^^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 "0324" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 4;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "5"^^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 "0259" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 5;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "6"^^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 "0250" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 6;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "7"^^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 "0710" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 7;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "8"^^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 "0210" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 8;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "9"^^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 "0272" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 9;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "10"^^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 "0370" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 10;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "11"^^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 "0730" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 11;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "12"^^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 "0450" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
], [
fhir:index 12;
fhir:ExplanationOfBenefit.item.sequence [ fhir:value "13"^^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 "0481" ] ] ];
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.servicedPeriod [
fhir:Period.start [ fhir:value "2017-05-23"^^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 "21" ] ];
fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ] ]
];
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 "outofnetwork" ] ] ]
], [
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/C4BBAdjudicationDiscriminator" ];
fhir:Coding.code [ fhir:value "billingnetworkstatus" ] ] ];
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:Coding.display [ fhir:value "In Network" ] ];
fhir:CodeableConcept.text [ fhir:value "Indicates the provider was in network for the service" ] ]
], [
fhir:index 2;
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.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 "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.total.amount [
fhir:Money.value [ fhir:value "7147.2"^^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 "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 "1542.01"^^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 "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 3;
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 "120"^^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://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 5;
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 "1393.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ] ]
], [
fhir:index 6;
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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