FHIR IG analytics| Package | hl7.fhir.us.carin-bb |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-EOBProfessional2.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit EOBProfessional2
Last updated: 2020-10-20 14:46:05-0400; Language: en
Profile: C4BB ExplanationOfBenefit Professional NonClinicianversion: 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
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency 68.8 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 34.8 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency 34.8 United States dollar adjudication
category: 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.
Amounts
Value Currency 0 United States dollar
item
sequence: 2
productOrService: Angiography, extremity, unilateral, radiological supervision and interpretation
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency -68.8 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency -34.8 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency -34.8 United States dollar adjudication
category: 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.
Amounts
Value Currency 0 United States dollar
item
sequence: 3
productOrService: Angiography, extremity, unilateral, radiological supervision and interpretation
serviced: 2020-08-04
location: HOSPITAL - INPATIENT HOSPITAL
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency 68.8 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 34.8 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency 34.8 United States dollar adjudication
category: 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.
Amounts
Value Currency 0 United States dollar
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
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency 751.2 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 224.11 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency 0 United States dollar adjudication
category: 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.
Amounts
Value Currency 224.11 United States dollar
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
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency 751.2 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 224.11 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency 224.11 United States dollar adjudication
category: 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.
Amounts
Value Currency 0 United States dollar
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
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency -751.2 United States dollar adjudication
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency -224.11 United States dollar adjudication
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar adjudication
category: Amount payable under the coverage
Amounts
Value Currency 0 United States dollar adjudication
category: 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.
Amounts
Value Currency -224.11 United States dollar
| 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 |
total
category: The total submitted amount for the claim or group or line item.
Amounts
Value Currency 820 United States dollar
total
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 258.91 United States dollar
total
category: Amount deducted from the eligible amount prior to adjudication.
Amounts
Value Currency 0 United States dollar
total
category: Patient Co-Payment
Amounts
Value Currency 0 United States dollar
total
category: 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.
Amounts
Value Currency 0 United States dollar
total
category: Amount payable under the coverage
Amounts
Value Currency 258.91 United States dollar
total
category: The amount of the member's liability.
Amounts
Value Currency 0 United States dollar
FHIR
FHIRsmith{
"resourceType": "ExplanationOfBenefit",
"id": "EOBProfessional2",
"meta": {
"lastUpdated": "2020-10-20T14:46:05-04:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": 68.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": 34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
},
{
"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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": -68.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": -34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": -34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
},
{
"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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": 68.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": 34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 34.8,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
},
{
"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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": 751.2,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": 224.11,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 224.11,
"currency": "USD"
}
}
]
},
{
"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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": 751.2,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": 224.11,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 224.11,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
},
{
"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"
}
]
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": -751.2,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": -224.11,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": -224.11,
"currency": "USD"
}
}
]
}
],
"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"
}
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "submitted",
"display": "Submitted Amount"
}
],
"text": "The total submitted amount for the claim or group or line item."
},
"amount": {
"value": 820,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "eligible",
"display": "Eligible Amount"
}
],
"text": "Amount of the change which is considered for adjudication."
},
"amount": {
"value": 258.91,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "deductible",
"display": "Deductible"
}
],
"text": "Amount deducted from the eligible amount prior to adjudication."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "copay",
"display": "CoPay"
}
],
"text": "Patient Co-Payment"
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "noncovered",
"display": "Noncovered"
}
],
"text": "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."
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"version": "1.0.1",
"code": "benefit",
"display": "Benefit Amount"
}
],
"text": "Amount payable under the coverage"
},
"amount": {
"value": 258.91,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "memberliability",
"display": "Member liability"
}
],
"text": "The amount of the member's liability."
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
}