FHIR IG analytics| Package | hl7.fhir.us.carin-bb |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-EOBProfessionalTransportation1.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit EOBProfessionalTransportation1
Last updated: 2022-09-10 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/ProfessionalTransportationEOBExample1
status: Active
type: Professional
use: Claim
patient: Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)
billablePeriod: 2022-09-10 --> (ongoing)
created: 2022-09-10 14:46:05-0400
insurer: UPMC Health Plan
provider: Organization ABC Ambulance Services
| Type | Party |
| Any benefit payable will be paid to the provider (Assignment of Benefit). | Organization ABC Ambulance Services |
outcome: Processing Complete
supportingInfo
sequence: 1
category: Date the claim was received by the payer.
timing: 2022-09-11
supportingInfo
sequence: 2
category: Patient Weight
value: 160 [lb_av]
supportingInfo
sequence: 3
category: Ambulance Transport Reason
reason: ambulance-transport-reason-codes: B (Patient was transported for the benefit of a preferred physician)
supportingInfo
sequence: 4
category: Transportation Distance
value: 21 [mi_i]
supportingInfo
sequence: 5
category: Transportation Distance
value: 22 [mi_i]
supportingInfo
sequence: 6
category: Round Trip Purpose
value: Trip to facility and then back home
supportingInfo
sequence: 7
category: Stretcher Purpose
value: Patient could not walk
supportingInfo
sequence: 8
category: Pick-up Location
value: Patient home; Pittsburgh; PA,15222
supportingInfo
sequence: 9
category: Drop-off Location
value: Orange Medical Group; Pittsburgh; PA,15222
supportingInfo
sequence: 10
category: Pick-up Location
value: Orange Medical Group; Pittsburgh; PA,15222
supportingInfo
sequence: 11
category: Drop-off Location
value: Patient home; Pittsburgh; PA,15222
| Sequence | Diagnosis[x] | Type |
| 1 | Athscl native arteries of left leg w ulceration of unsp site | The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. |
item
sequence: 1
informationSequence: 2, 3, 4, 6, 7, 10, 11
productOrService: Ambulance service, basic life support, non-emergency transport (BLS)
serviced: 2022-09-10
location: Ambulance - Land
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 40.35 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 40.35 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 40.35 United States dollar
item
sequence: 2
informationSequence: 2, 3, 5, 6, 7, 8, 9
productOrService: Ambulance service, basic life support, non-emergency transport (BLS)
serviced: 2022-09-10
location: Ambulance - Land
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 42.62 United States dollar adjudication
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 42.62 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 42.62 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 82.97 United States dollar
total
category: Amount of the change which is considered for adjudication.
Amounts
Value Currency 82.97 United States dollar
total
category: Amount payable under the coverage
Amounts
Value Currency 82.97 United States dollar
total
category: The amount of the member's liability.
Amounts
Value Currency 0 United States dollar
FHIR
FHIRsmith{
"resourceType": "ExplanationOfBenefit",
"id": "EOBProfessionalTransportation1",
"meta": {
"lastUpdated": "2022-09-10T14:46:05-04:00",
"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": "ProfessionalTransportationEOBExample1"
}
],
"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": "2022-09-10"
},
"created": "2022-09-10T14:46:05-04:00",
"insurer": {
"reference": "Organization/Payer2",
"display": "UPMC Health Plan"
},
"provider": {
"reference": "Organization/ProviderTransportationOrganization1"
},
"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/ProviderTransportationOrganization1"
}
},
"outcome": "complete",
"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": "2022-09-11"
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "patientweight"
}
]
},
"valueQuantity": {
"value": 160,
"unit": "[lb_av]",
"system": "http://unitsofmeasure.org"
}
},
{
"sequence": 3,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "ambulancetransportreason"
}
]
},
"reason": {
"system": "https://x12.org/codesystem.x12.org/ambulance-transport-reason-codes",
"code": "B",
"display": "Patient was transported for the benefit of a preferred physician"
}
},
{
"sequence": 4,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "transportationdistance"
}
]
},
"valueQuantity": {
"value": 21,
"unit": "[mi_i]",
"system": "http://unitsofmeasure.org"
}
},
{
"sequence": 5,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "transportationdistance"
}
]
},
"valueQuantity": {
"value": 22,
"unit": "[mi_i]",
"system": "http://unitsofmeasure.org"
}
},
{
"sequence": 6,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "roudtrippurpose"
}
]
},
"valueString": "Trip to facility and then back home"
},
{
"sequence": 7,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "stretcherpurpose"
}
]
},
"valueString": "Patient could not walk"
},
{
"sequence": 8,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "pickuplocation"
}
]
},
"valueString": "Patient home; Pittsburgh; PA,15222"
},
{
"sequence": 9,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "dropofflocation"
}
]
},
"valueString": "Orange Medical Group; Pittsburgh; PA,15222"
},
{
"sequence": 10,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "pickuplocation"
}
]
},
"valueString": "Orange Medical Group; Pittsburgh; PA,15222"
},
{
"sequence": 11,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "dropofflocation"
}
]
},
"valueString": "Patient home; Pittsburgh; PA,15222"
}
],
"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."
}
]
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/Coverage1"
}
}
],
"item": [
{
"sequence": 1,
"informationSequence": [
2,
3,
4,
6,
7,
10,
11
],
"productOrService": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "A0428",
"display": "Ambulance service, basic life support, non-emergency transport (BLS)"
}
]
},
"servicedDate": "2022-09-10",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "41"
}
],
"text": "Ambulance - Land"
},
"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": 40.35,
"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": 40.35,
"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": 40.35,
"currency": "USD"
}
}
]
},
{
"sequence": 2,
"informationSequence": [
2,
3,
5,
6,
7,
8,
9
],
"productOrService": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "A0428",
"display": "Ambulance service, basic life support, non-emergency transport (BLS)"
}
]
},
"servicedDate": "2022-09-10",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "41"
}
],
"text": "Ambulance - Land"
},
"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": 42.62,
"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": 42.62,
"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": 42.62,
"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": 82.97,
"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": 82.97,
"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": 82.97,
"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"
}
}
]
}