FHIR IG analytics| Package | hl7.fhir.us.carin-bb.r4b |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-BB-EOBInpatient2-nonfinancial.json |
| FHIR Version | R4B |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit BB-EOBInpatient2-nonfinancial
Last updated: 2020-04-28 15:39:36-0400
Profile: C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: null2.1.0)
identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber/InpatientEOBExample1
status: Active
type: Institutional
subType: Inpatient
use: Claim
patient: Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)
billablePeriod: 2017-05-23 --> 2017-05-23
created: 2017-06-01 00:00:00-0400
insurer: UPMC Health Plan
provider: Organization Green Medical Group
| Type | Party |
| Any benefit payable will be paid to the provider (Assignment of Benefit). | Organization Blue Medical Group |
outcome: Processing Complete
careTeam
sequence: 1
provider: Practitioner Jack Brown
role: The attending physician
careTeam
sequence: 2
provider: Practitioner Jack Brown
role: The referring physician
supportingInfo
sequence: 2
category: Admission Period
timing: 2017-05-23 --> (ongoing)
supportingInfo
sequence: 1
category: Claim Received Date
timing: 2017-06-01
diagnosis
sequence: 1
diagnosis: Non-ST elevation (NSTEMI) myocardial infarction
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.
diagnosis
sequence: 2
diagnosis: Athscl heart disease of native cor art w oth ang pctrs
type: Required when other conditions coexist or develop subsequently during the treatment
diagnosis
sequence: 3
diagnosis: Hyperlipidemia, unspecified
type: Required when other conditions coexist or develop subsequently during the treatment
diagnosis
sequence: 4
diagnosis: Unspecified osteoarthritis, unspecified site
type: Required when other conditions coexist or develop subsequently during the treatment
procedure
sequence: 1
type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis
date: 2017-05-23
procedure: Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach
procedure
sequence: 2
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: Fluoroscopy of Multiple Coronary Arteries using Other Contrast
procedure
sequence: 3
type: Other procedures performed during the inpatient institutional admission
date: 2017-05-23
procedure: Fluoroscopy of Left Heart using Other Contrast
item
sequence: 1
revenue: 0301
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 2
revenue: 0260
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 3
revenue: 0305
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 4
revenue: 0324
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 5
revenue: 0259
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 6
revenue: 0250
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 7
revenue: 0710
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 8
revenue: 0210
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 9
revenue: 0272
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 10
revenue: 0370
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 11
revenue: 0730
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 12
revenue: 0450
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
item
sequence: 13
revenue: 0481
productOrService: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
serviced: 2017-05-23 --> (ongoing)
location: HOSPITAL - INPATIENT HOSPITAL
| Category | Reason |
| Benefit Payment Status | Out Of Network |
| Billing Network Status | Indicates the provider was in network for the service |
FHIR
FHIRsmith{
"resourceType": "ExplanationOfBenefit",
"id": "BB-EOBInpatient2-nonfinancial",
"meta": {
"lastUpdated": "2020-04-28T15:39:36-04:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis|2.1.0"
]
},
"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.upmchealthplan.com/fhir/EOBIdentifier",
"value": "InpatientEOBExample1"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "institutional"
}
],
"text": "Institutional"
},
"subType": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
"code": "inpatient"
}
],
"text": "Inpatient"
},
"use": "claim",
"patient": {
"reference": "Patient/Patient1"
},
"billablePeriod": {
"start": "2017-05-23",
"end": "2017-05-23"
},
"created": "2017-06-01T00:00:00-04:00",
"insurer": {
"reference": "Organization/Payer2",
"display": "UPMC Health Plan"
},
"provider": {
"reference": "Organization/ProviderOrganization3"
},
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider",
"display": "Provider"
}
],
"text": "Any benefit payable will be paid to the provider (Assignment of Benefit)."
},
"party": {
"reference": "Organization/ProviderOrganization4"
}
},
"outcome": "complete",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/Practitioner2"
},
"role": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code": "attending",
"display": "Attending"
}
],
"text": "The attending physician"
}
},
{
"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": 2,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "admissionperiod"
}
]
},
"timingPeriod": {
"start": "2017-05-23"
}
},
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "clmrecvddate"
}
]
},
"timingDate": "2017-06-01"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"code": "I21.4"
}
]
},
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"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": "I25.118"
}
]
},
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code": "other",
"display": "Other"
}
],
"text": "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence": 3,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"code": "E78.5"
}
]
},
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code": "other",
"display": "Other"
}
],
"text": "Required when other conditions coexist or develop subsequently during the treatment"
}
]
},
{
"sequence": 4,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"code": "M19.90"
}
]
},
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType",
"code": "other",
"display": "Other"
}
],
"text": "Required when other conditions coexist or develop subsequently during the treatment"
}
]
}
],
"procedure": [
{
"sequence": 1,
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code": "principal",
"display": "Principal"
}
],
"text": "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
}
],
"date": "2017-05-23",
"procedureCodeableConcept": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/ICD10",
"code": "4A023N7"
}
]
}
},
{
"sequence": 2,
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code": "other",
"display": "Other"
}
],
"text": "Other procedures performed during the inpatient institutional admission"
}
],
"date": "2017-05-23",
"procedureCodeableConcept": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/ICD10",
"code": "B211YZZ"
}
]
}
},
{
"sequence": 3,
"type": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType",
"code": "other",
"display": "Other"
}
],
"text": "Other procedures performed during the inpatient institutional admission"
}
],
"date": "2017-05-23",
"procedureCodeableConcept": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/ICD10",
"code": "B215YZZ"
}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/Coverage2"
}
}
],
"item": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0301"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 2,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0260"
}
]
},
"productOrService": {
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{
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"code": "99231"
}
]
},
"servicedPeriod": {
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},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 3,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0305"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 4,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0324"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
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},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 5,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0259"
}
]
},
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}
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},
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},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 6,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0250"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 7,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0710"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 8,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0210"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 9,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0272"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 10,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0370"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 11,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0730"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 12,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0450"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21"
}
],
"text": "HOSPITAL - INPATIENT HOSPITAL"
}
},
{
"sequence": 13,
"revenue": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/RevenueCodes",
"code": "0481"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99231"
}
]
},
"servicedPeriod": {
"start": "2017-05-23"
},
"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": "outofnetwork"
}
]
}
},
{
"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",
"display": "In Network"
}
],
"text": "Indicates the provider was in network for the service"
}
}
]
}