FHIR IG analytics| Package | hl7.fhir.us.carin-bb |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-BB-EOBProfessional2-nonfinancial.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit BB-EOBProfessional2-nonfinancial
Last updated: 2020-10-20 14:46:05-0400; Language: en
Profile: C4BB ExplanationOfBenefit Professional NonClinician Basisversion: null2.2.0)
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/ProfessionalEOBExample1
status: Active
type: Professional
use: Claim
patient: Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)
billablePeriod: 2020-08-04 --> 2020-08-04
created: 2020-08-24 00:00:00-0400
insurer: UPMC Health Plan
provider: Organization Orange Medical Group
| Type | Party |
| Any benefit payable will be paid to the provider (Assignment of Benefit). | Organization Orange Medical Group |
outcome: Processing Complete
careTeam
sequence: 1
provider: Practitioner John Smith
role: The primary care provider.
careTeam
sequence: 2
provider: Practitioner Jack Brown
role: The referring physician
| Sequence | Category | Timing[x] |
| 1 | Date the claim was received by the payer. | 2020-08-24 |
diagnosis
sequence: 1
diagnosis: Athscl native arteries of left leg w ulceration of unsp site
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.
diagnosis
sequence: 2
diagnosis: Non-prs chronic ulc unsp prt of l low leg w unsp severity
type: Required when necessary to report additional diagnoses on professional and non-clinician claims
item
sequence: 1
productOrService: Angiography, extremity, unilateral, radiological supervision and interpretation
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
item
sequence: 2
productOrService: Angiography, extremity, unilateral, radiological supervision and interpretation
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
item
sequence: 3
productOrService: Angiography, extremity, unilateral, radiological supervision and interpretation
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
item
sequence: 4
productOrService: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
item
sequence: 5
productOrService: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
item
sequence: 6
productOrService: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
Adjudications
Category Reason Benefit Payment Status In Network
| Category | Reason |
| Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. | Indicates the provider was in network for the service |
FHIR
FHIRsmith{
"resourceType": "ExplanationOfBenefit",
"id": "BB-EOBProfessional2-nonfinancial",
"meta": {
"lastUpdated": "2020-10-20T14:46:05-04:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician-Basis|2.2.0"
]
},
"language": "en",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code": "uc",
"display": "Unique Claim ID"
}
],
"text": "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
},
"system": "https://www.example.com/fhir/EOBIdentifier",
"value": "ProfessionalEOBExample1"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"version": "1.0.1",
"code": "professional"
}
],
"text": "Professional"
},
"use": "claim",
"patient": {
"reference": "Patient/Patient1"
},
"billablePeriod": {
"start": "2020-08-04",
"end": "2020-08-04"
},
"created": "2020-08-24T00:00:00-04:00",
"insurer": {
"reference": "Organization/Payer2",
"display": "UPMC Health Plan"
},
"provider": {
"reference": "Organization/ProviderOrganization1"
},
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"version": "1.0.1",
"code": "provider",
"display": "Provider"
}
],
"text": "Any benefit payable will be paid to the provider (Assignment of Benefit)."
},
"party": {
"reference": "Organization/ProviderOrganization1"
}
},
"outcome": "complete",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/Practitioner1"
},
"role": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"version": "1.0.0",
"code": "primary",
"display": "Primary provider"
}
],
"text": "The primary care provider."
}
},
{
"sequence": 2,
"provider": {
"reference": "Practitioner/Practitioner2"
},
"role": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code": "referring",
"display": "Referring"
}
],
"text": "The referring physician"
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "clmrecvddate",
"display": "Claim Received Date"
}
],
"text": "Date the claim was received by the payer."
},
"timingDate": "2020-08-24"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"code": "I70.249"
}
]
},
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"version": "1.0.1",
"code": "principal",
"display": "Principal Diagnosis"
}
],
"text": "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
}
]
},
{
"sequence": 2,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"code": "L97.929"
}
]
},
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code": "secondary",
"display": "secondary"
}
],
"text": "Required when necessary to report additional diagnoses on professional and non-clinician claims"
}
]
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/Coverage1"
}
}
],
"item": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "75710"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
},
{
"sequence": 2,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "75710"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
},
{
"sequence": 3,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "75710"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
},
{
"sequence": 4,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "37228"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
},
{
"sequence": 5,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "37228"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
},
{
"sequence": 6,
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "37228"
}
]
},
"servicedDate": "2020-08-04",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "benefitpaymentstatus"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork"
}
]
}
}
]
}
],
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "billingnetworkstatus",
"display": "Billing Network Status"
}
],
"text": "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code": "innetwork",
"display": "In Network"
}
],
"text": "Indicates the provider was in network for the service"
}
}
]
}