FHIRsmith: ExplanationOfBenefit/ExplanationOfBenefit-BB-EOBOutpatient2-nonfinancial.json

FHIR IG analytics

Package	hl7.fhir.us.carin-bb.r4b
Resource Type	ExplanationOfBenefit
Id	ExplanationOfBenefit-BB-EOBOutpatient2-nonfinancial.json
FHIR Version	R4B

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Narrative

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

Generated Narrative: ExplanationOfBenefit BB-EOBOutpatient2-nonfinancial

Last updated: 2020-10-13 11:10:24-0400;

Information Source: Organization/PayerOrganizationExample1

Profile: C4BB ExplanationOfBenefit Outpatient 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/OutpatientEOBExample1

status: Active

type: Institutional

subType: Outpatient

use: Claim

patient: Johnny Example1 Male, DoB: 1986-01-01 ( Member Number)

billablePeriod: 2020-09-29 --> 2020-09-29

created: 2020-10-10 00:00:00-0400

insurer: UPMC Health Plan

provider: Organization Black Medical Group

Payees

Type

Party

Any benefit payable will be paid to the provider (Assignment of Benefit).

Organization White Medical Group

outcome: Processing Complete

careTeam
sequence: 1
provider: Practitioner John Smith
role: The attending physician

careTeam
sequence: 2
provider: Practitioner Jane Williams
role: The referring physician

SupportingInfos

Sequence

Category

Timing[x]

Claim Received Date

2020-10-10

diagnosis
sequence: 1
diagnosis: Orthostatic hypotension
type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.

diagnosis
sequence: 2
diagnosis: Orthostatic hypotension
type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis
sequence: 3
diagnosis: Non-pressure chronic ulcer oth prt left foot w unsp severity
type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis
sequence: 4
diagnosis: Peripheral vascular disease, unspecified
type: Required when other conditions coexist or develop subsequently during the treatment

Insurances

Focal

Coverage

true

Coverage: identifier = An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status = active; subscriberId = 888009335; dependent = 01; relationship = Self; period = 2020-01-01 --> (ongoing); network = GR5-HMO DEDUCTIBLE

item
sequence: 1
revenue: 0551
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: 2020-09-29
location: HOME

item
sequence: 2
revenue: 0023
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: 2020-09-29
location: HOME

Adjudications

Category

Reason

Benefit Payment Status

In Network

Source1

{
  "resourceType": "ExplanationOfBenefit",
  "id": "BB-EOBOutpatient2-nonfinancial",
  "meta": {
    "lastUpdated": "2020-10-13T11:10:24-04:00",
    "source": "Organization/PayerOrganizationExample1",
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-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": "OutpatientEOBExample1"
    }
  ],
  "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": "outpatient"
      }
    ],
    "text": "Outpatient"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/Patient1"
  },
  "billablePeriod": {
    "start": "2020-09-29",
    "end": "2020-09-29"
  },
  "created": "2020-10-10T00:00:00-04:00",
  "insurer": {
    "reference": "Organization/Payer2",
    "display": "UPMC Health Plan"
  },
  "provider": {
    "reference": "Organization/ProviderOrganization5"
  },
  "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/ProviderOrganization6"
    }
  },
  "outcome": "complete",
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/Practitioner1"
      },
      "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/Practitioner3"
      },
      "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"
          }
        ]
      },
      "timingDate": "2020-10-10"
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "I95.1"
          }
        ]
      },
      "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": "I95.1"
          }
        ]
      },
      "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": "L97.529"
          }
        ]
      },
      "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": "I73.9"
          }
        ]
      },
      "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"
        }
      ]
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/Coverage1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "revenue": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code": "0551"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "99231"
          }
        ]
      },
      "servicedDate": "2020-09-29",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code": "12"
          }
        ],
        "text": "HOME"
      }
    },
    {
      "sequence": 2,
      "revenue": {
        "coding": [
          {
            "system": "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code": "0023"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "99231"
          }
        ]
      },
      "servicedDate": "2020-09-29",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code": "12"
          }
        ],
        "text": "HOME"
      }
    }
  ],
  "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"
          }
        ]
      }
    }
  ]
}