FHIRsmith: ExplanationOfBenefit/ExplanationOfBenefit-EOBProfessional1.json

FHIR IG analytics

Package	hl7.fhir.us.carin-bb
Resource Type	ExplanationOfBenefit
Id	ExplanationOfBenefit-EOBProfessional1.json
FHIR Version	R4

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: ExplanationOfBenefit EOBProfessional1

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

Profile: C4BB ExplanationOfBenefit Professional NonClinicianversion: null2.2.0)

identifier: Unique Claim ID/AW123412341234123412341234123413

status: Active

type: Professional

use: Claim

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

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

created: 2019-07-02 00:00:00+0000

insurer: XXX Health Plan

provider: XXX Health Plan

Payees

Type

Party

Provider

Organization Orange Medical Group

outcome: Partial Processing

supportingInfo
sequence: 3
category: Claim Received Date
timing: 2011-05-30

supportingInfo
sequence: 4
category: Service Facility
value: Organization Orange Medical Group

supportingInfo
sequence: 5
category: Medical Record Number
value: 1234-234-1243-12345678901m

supportingInfo
sequence: 6
category: Patient Account Number
value: 1234-234-1243-12345678901a

Diagnoses

Sequence

Diagnosis[x]

Type

Concussion w LOC of 30 minutes or less, init

Principal Diagnosis

Insurances

Focal

Coverage

true

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

item
sequence: 1
productOrService: Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
serviced: 2019-07-02
location: Office
adjudication
category: Benefit Payment Status
reason: Other
adjudication
category: Submitted Amount
Amounts
- Value Currency
* 250 United States dollar
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 200 United States dollar

Adjudications

Category

Reason

Billing Network Status

In Network

Rendering Network Status

In Network

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

total
category: Benefit Amount
Amounts
- Value Currency
* 200 United States dollar

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

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

payment
type: Paid
Adjustments
- Value Currency
* -50 United States dollar
Amounts
- Value Currency
* 200 United States dollar

Source1

{
  "resourceType": "ExplanationOfBenefit",
  "id": "EOBProfessional1",
  "meta": {
    "lastUpdated": "2019-12-12T09:14:11+00:00",
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.2.0"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code": "uc"
          }
        ]
      },
      "system": "https://www.example.com/fhir/EOBIdentifier",
      "value": "AW123412341234123412341234123413"
    }
  ],
  "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/Patient2"
  },
  "billablePeriod": {
    "start": "2019-01-01",
    "end": "2019-10-31"
  },
  "created": "2019-07-02T00:00:00+00:00",
  "insurer": {
    "reference": "Organization/Payer1",
    "display": "XXX Health Plan"
  },
  "provider": {
    "reference": "Organization/ProviderOrganization1",
    "display": "XXX Health Plan"
  },
  "payee": {
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/payeetype",
          "version": "1.0.1",
          "code": "provider",
          "display": "Provider"
        }
      ]
    },
    "party": {
      "reference": "Organization/ProviderOrganization1"
    }
  },
  "outcome": "partial",
  "supportingInfo": [
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "clmrecvddate"
          }
        ]
      },
      "timingDate": "2011-05-30"
    },
    {
      "sequence": 4,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "servicefacility"
          }
        ]
      },
      "valueReference": {
        "reference": "Organization/ProviderOrganization1"
      }
    },
    {
      "sequence": 5,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "medicalrecordnumber"
          }
        ]
      },
      "valueString": "1234-234-1243-12345678901m"
    },
    {
      "sequence": 6,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "patientaccountnumber"
          }
        ]
      },
      "valueString": "1234-234-1243-12345678901a"
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "S06.0X1A"
          }
        ]
      },
      "type": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "version": "1.0.1",
              "code": "principal"
            }
          ]
        }
      ]
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/Coverage3"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "97110",
            "display": "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility"
          }
        ]
      },
      "servicedDate": "2019-07-02",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code": "11",
            "display": "Office"
          }
        ]
      },
      "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": "other"
              }
            ]
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "version": "1.0.1",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 250,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "version": "1.0.1",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 200,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "adjudication": [
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "billingnetworkstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "renderingnetworkstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "version": "1.0.1",
            "code": "submitted"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 250,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "version": "1.0.1",
            "code": "benefit"
          }
        ],
        "text": "Benefit Amount"
      },
      "amount": {
        "value": 200,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidtoprovider"
          }
        ],
        "text": "Payment Amount"
      },
      "amount": {
        "value": 200,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidbypatient"
          }
        ],
        "text": "Patient Pay Amount"
      },
      "amount": {
        "value": 0,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
          "code": "paid",
          "display": "Paid"
        }
      ]
    },
    "adjustment": {
      "value": -50,
      "currency": "USD"
    },
    "amount": {
      "value": 200,
      "currency": "USD"
    }
  }
}