-
Notifications
You must be signed in to change notification settings - Fork 4
/
Copy pathcarin_bundle_patient_888.json
2834 lines (2828 loc) · 133 KB
/
carin_bundle_patient_888.json
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905
906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
995
996
997
998
999
1000
{
"type": "transaction",
"entry": [
{
"resource": {
"resourceType": "Patient",
"id": "888",
"meta": {
"lastUpdated": "2020-07-07T13:26:22.0314215+00:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient|2.0.0"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Johnny Smith </b> male, DoB: 1986-01-01 ( Member Number: 1234-234-1243-12345678901)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td>true</td><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}\">unknown</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Other Ids (see the one above)\">Other Id:</td><td colspan=\"3\">Unique Member ID: 1234-234-1243-12345678901u</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: (301)666-1212</li><li>123 Main Street Pittsburgh PA 12519 </li></ul></td></tr></table></div>"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MB"
}
]
},
"system": "http://inferno.healthit.gov/reference-server/r4/uniquememberidentifier",
"value": "1234-234-1243-12345678901"
},
{
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code": "um"
}
]
},
"system": "https://www.xxxhealthplan.com/fhir/uniquememberidentifier",
"value": "1234-234-1243-12345678901u"
}
],
"active": true,
"name": [
{
"family": "Smith",
"given": [
"Johnny"
]
}
],
"telecom": [
{
"system": "phone",
"value": "(301)666-1212",
"rank": 2,
"use": "home"
}
],
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en"
}
],
"text" : "English"
},
"preferred" : true
}
],
"gender": "male",
"deceasedBoolean": false,
"birthDate": "1986-01-01",
"address": [
{
"type": "physical",
"line": [
"123 Main Street"
],
"city": "Pittsburgh",
"state": "PA",
"postalCode": "12519",
"country": "USA"
}
],
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"code": "UNK"
}
]
}
},
"request": {
"method": "PUT",
"url": "Patient/888"
}
},
{
"resource": {
"resourceType": "Coverage",
"id": "c4bb-Coverage",
"meta": {
"lastUpdated": "2020-10-30T09:48:01.8462752-04:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.0.0"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "\u003Cdiv xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"\u003E\u003Cp class=\"res-header-id\"\u003E\u003Cb\u003EGenerated Narrative: Coverage c4bb-Coverage\u003C/b\u003E\u003C/p\u003E\u003Ca name=\"c4bb-Coverage\"\u003E \u003C/a\u003E\u003Ca name=\"hcc4bb-Coverage\"\u003E \u003C/a\u003E\u003Ca name=\"c4bb-Coverage-en-US\"\u003E \u003C/a\u003E\u003Cdiv style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"\u003E\u003Cp style=\"margin-bottom: 0px\"\u003ELast updated: 2020-10-30 09:48:01-0400; Language: en-US\u003C/p\u003E\u003Cp style=\"margin-bottom: 0px\"\u003EProfile: \u003Ca href=\"StructureDefinition-C4BB-Coverage.html\"\u003EC4BB Coverageversion: {0}2.0.0)\u003C/a\u003E\u003C/p\u003E\u003C/div\u003E\u003Cp\u003E\u003Cb\u003Eidentifier\u003C/b\u003E: An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier./88800933501\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Estatus\u003C/b\u003E: Active\u003C/p\u003E\u003Cp\u003E\u003Cb\u003EpolicyHolder\u003C/b\u003E: \u003Ca href=\"Patient-888.html\"\u003EJohnny Smith Male, DoB: 1986-01-01 ( Member Number)\u003C/a\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Esubscriber\u003C/b\u003E: \u003Ca href=\"Patient-888.html\"\u003EJohnny Smith Male, DoB: 1986-01-01 ( Member Number)\u003C/a\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003EsubscriberId\u003C/b\u003E: 888009335\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Ebeneficiary\u003C/b\u003E: \u003Ca href=\"Patient-888.html\"\u003EJohnny Smith Male, DoB: 1986-01-01 ( Member Number)\u003C/a\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Edependent\u003C/b\u003E: 01\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Erelationship\u003C/b\u003E: \u003Cspan title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\"\u003ESelf\u003C/span\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Eperiod\u003C/b\u003E: 2020-01-01 --> (ongoing)\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Epayor\u003C/b\u003E: \u003Ca href=\"Organization-c4bb-Organization.html\"\u003EUPMC Health Plan\u003C/a\u003E\u003C/p\u003E\u003Cblockquote\u003E\u003Cp\u003E\u003Cb\u003Eclass\u003C/b\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Etype\u003C/b\u003E: \u003Cspan title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}\"\u003EAn employee group\u003C/span\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Evalue\u003C/b\u003E: MCHMO1\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Ename\u003C/b\u003E: MEDICARE HMO PLAN\u003C/p\u003E\u003C/blockquote\u003E\u003Cblockquote\u003E\u003Cp\u003E\u003Cb\u003Eclass\u003C/b\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Etype\u003C/b\u003E: \u003Cspan title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\"\u003EA specific suite of benefits.\u003C/span\u003E\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Evalue\u003C/b\u003E: GR5\u003C/p\u003E\u003Cp\u003E\u003Cb\u003Ename\u003C/b\u003E: GR5-HMO DEDUCTIBLE\u003C/p\u003E\u003C/blockquote\u003E\u003Cp\u003E\u003Cb\u003Enetwork\u003C/b\u003E: GR5-HMO DEDUCTIBLE\u003C/p\u003E\u003C/div\u003E"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MB",
"display": "Member Number"
}
],
"text": "An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier."
},
"system": "https://www.upmchealthplan.com/fhir/memberidentifier",
"value": "88800933501",
"assigner": {
"reference": "Organization/c4bb-Organization",
"display": "UPMC Health Plan"
}
}
],
"status": "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "HIP"
}
],
"text" : "health insurance plan policy"
},
"policyHolder": {
"reference": "Patient/888"
},
"subscriber": {
"reference": "Patient/888"
},
"subscriberId": "888009335",
"beneficiary": {
"reference": "Patient/888"
},
"dependent": "01",
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self"
}
],
"text": "Self"
},
"period": {
"start": "2020-01-01"
},
"payor": [
{
"reference": "Organization/c4bb-Organization"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "group",
"display": "Group"
}
],
"text": "An employee group"
},
"value": "MCHMO1",
"name": "MEDICARE HMO PLAN"
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan",
"display": "Plan"
}
],
"text": "A specific suite of benefits."
},
"value": "GR5",
"name": "GR5-HMO DEDUCTIBLE"
}
],
"network": "GR5-HMO DEDUCTIBLE"
},
"request": {
"method": "PUT",
"url": "Coverage/c4bb-Coverage"
}
},
{
"resource": {
"resourceType" : "Organization",
"id" : "c4bb-Organization",
"meta" : {
"lastUpdated" : "2020-05-04T03:02:01-04:00",
"profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.0.0"]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Organization Providerc4bb-Organization</b></p><a name=\"Providerc4bb-Organization\"> </a><a name=\"hcProviderc4bb-Organization\"> </a><a name=\"Providerc4bb-Organization-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2020-05-04 03:02:01-0400</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-Organization.html\">C4BB Organizationversion: {0}2.0.0)</a></p></div><p><b>identifier</b>: National Provider Identifier/9941339100</p><p><b>active</b>: true</p><p><b>name</b>: Orange Medical Group</p><p><b>address</b>: Attn: Orange Medical Group Pittsburgh PA 15222 USA </p><h3>Contacts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Telecom</b></td></tr><tr><td style=\"display: none\">*</td><td>ph: 555-555-5510(Work)</td></tr></table></div>"
},
"identifier" : [{
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NPI",
"display" : "National Provider Identifier"
}],
"text" : "National Provider Identifier"
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "9941339100"
},
{
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "TAX",
"display" : "Tax ID number"
}],
"text" : "Tax ID number"
},
"system" : "urn:oid:2.16.840.1.113883.4.4",
"value" : "060101507"
},
{
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "payerid",
"display" : "Payer ID"
}],
"text" : "Payer ID"
}
},
{
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "naiccode",
"display" : "NAIC Code"
}],
"text" : "NAIC Code"
},
"system" : "urn:oid:2.16.840.1.113883.6.300",
"value" : "13703"
}],
"active" : true,
"name" : "Orange Medical Group",
"address" : [{
"line" : ["Attn: Orange Medical Group"],
"city" : "Pittsburgh",
"state" : "PA",
"postalCode" : "15222",
"country" : "USA"
}],
"telecom": [
{
"system": "phone",
"value": "(555)555-5510",
"rank": 1
}
]
},
"request": {
"method": "PUT",
"url": "Organization/c4bb-Organization"
}
},
{
"resource": {
"resourceType" : "Practitioner",
"id" : "c4bb-Practitioner",
"meta" : {
"lastUpdated" : "2020-05-04T03:02:01-04:00",
"profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.0.0"]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Practitioner c4bb-Practitioner</b></p><a name=\"c4bb-Practitioner\"> </a><a name=\"hcc4bb-Practitioner\"> </a><a name=\"c4bb-Practitioner-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2020-05-04 03:02:01-0400</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-Practitioner.html\">C4BB Practitionerversion: {0}2.0.0)</a></p></div><p><b>identifier</b>: National Provider Identifier/9941339100</p><p><b>active</b>: true</p><p><b>name</b>: John Smith </p></div>"
},
"identifier" : [{
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NPI",
"display" : "National Provider Identifier"
}],
"text" : "National Provider Identifier"
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "9941339100"
},
{
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "TAX",
"display" : "Tax ID number"
}],
"text" : "Tax ID number"
},
"system" : "urn:oid:2.16.840.1.113883.4.4",
"value" : "060101507"
}],
"active" : true,
"name" : [{
"family" : "Smith",
"given" : ["John"],
"prefix" : ["Dr."]
}],
"address" : [{
"line" : ["Attn: Orange Medical Group"],
"city" : "Pittsburgh",
"state" : "PA",
"postalCode" : "15222",
"country" : "USA"
}],
"telecom": [
{
"system": "phone",
"value": "(555)555-5510",
"rank": 1
}
]
},
"request": {
"method": "PUT",
"url": "Practitioner/c4bb-Practitioner"
}
},
{
"resource": {
"resourceType" : "RelatedPerson",
"id" : "c4bb-RelatedPerson",
"meta" : {
"lastUpdated" : "2020-05-04T03:02:01-04:00",
"profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-RelatedPerson|2.0.0"]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: RelatedPerson c4bb-RelatedPerson</b></p><a name=\"c4bb-RelatedPerson\"> </a><a name=\"hcc4bb-RelatedPerson\"> </a><a name=\"c4bb-RelatedPerson-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2020-05-04 03:02:01-0400</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-RelatedPerson.html\">C4BB RelatedPersonversion: {0}2.0.0)</a></p></div><p><b>active</b>: true</p><p><b>patient</b>: <a href=\"Patient-888.html\">Johnny Smith Male, DoB: 1986-01-01 ( Member Number)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-RoleCode MTH}\">mother</span></p><p><b>name</b>: Mary Jones </p><p><b>telecom</b>: ph: (301)666-1212</p><p><b>address</b>: 123 Main Street Pittsburgh PA 12519 </p></div>"
},
"active" : true,
"patient" : {
"reference" : "Patient/888"
},
"relationship" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code" : "MTH"
}]
}],
"name" : [{
"family" : "Jones",
"given" : ["Mary"]
}],
"telecom" : [{
"system" : "phone",
"value" : "(301)666-1212",
"rank" : 2
}],
"address" : [{
"type" : "physical",
"line" : ["123 Main Street"],
"city" : "Pittsburgh",
"state" : "PA",
"postalCode" : "12519"
}]
},
"request": {
"method": "PUT",
"url": "RelatedPerson/c4bb-RelatedPerson"
}
},
{
"resource": {
"resourceType" : "ExplanationOfBenefit",
"id" : "c4bb-EOBInpatient",
"meta" : {
"lastUpdated" : "2019-12-12T09:14:11+00:00",
"profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.0"]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit c4bb-EOBInpatient</b></p><a name=\"c4bb-EOBInpatient\"> </a><a name=\"hcc4bb-EOBInpatient\"> </a><a name=\"c4bb-EOBInpatient-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2019-12-12 09:14:11+0000; Language: en-US</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-c4bb-EOBInpatient-Inpatient-Institutional-Basis.html\">C4BB ExplanationOfBenefit Inpatient Institutional Basisversion: {0}2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID/AW123412341234123412341234123412</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>subType</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType inpatient}\">Inpatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-888.html\">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.:\u00a088800933501)</a></p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-11-02 00:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-c4bb-Organization.html\">XXX Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-Providerc4bb-Organization.html\">XXX Health Plan</a></p><p><b>outcome</b>: Partial Processing</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}\">Admission Period</span></p><p><b>timing</b>: 2011-05-23 --> 2011-05-25</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Claim Received Date</span></p><p><b>timing</b>: 2011-05-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType typeofbill}\">Type of Bill</span></p><p><b>code</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/TypeOfBill Dummy}\">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType pointoforigin}\">Point Of Origin</span></p><p><b>code</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/PointOfOrigin Dummy}\">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admtype}\">Admission Type</span></p><p><b>code</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit Dummy}\">Dummy</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType discharge-status}\">Discharge Status</span></p><p><b>code</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/PatDischargeStatus 11}\">11</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType medicalrecordnumber}\">Medical Record Number</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientaccountnumber}\">Patient Account Number</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.0X1A}\">Concussion w LOC of 30 minutes or less, init</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-c4bb-Coverage.html\">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</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes Dummy}\">Dummy</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/data-absent-reason not-applicable}\">Not Applicable</span></td><td>2019-11-02</td></tr></table><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}\">Billing Network Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr></table></div>"
},
"identifier" : [{
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123412"
}],
"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/888"
},
"billablePeriod" : {
"start" : "2019-01-01",
"end" : "2019-10-31"
},
"created" : "2019-11-02T00:00:00+00:00",
"insurer" : {
"reference" : "Organization/c4bb-Organization",
"display" : "XXX Health Plan"
},
"provider" : {
"reference" : "Organization/c4bb-Organization",
"display" : "XXX Health Plan"
},
"related": [{
"relationship": {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code" : "prior"
}]
},
"reference": {
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123413"
}
}],
"payee": {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "other"
}]
},
"party": {
"reference" : "RelatedPerson/c4bb-RelatedPerson",
"display" : "Mary Jones"
}
},
"outcome" : "partial",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/c4bb-Practitioner"
},
"role" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code" : "primary",
"display" : "Primary provider"
}
],
"text" : "The primary care provider"
}
}],
"supportingInfo" : [{
"sequence" : 2,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admissionperiod"
}]
},
"timingPeriod" : {
"start" : "2011-05-23",
"end" : "2011-05-25"
}
},
{
"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" : "typeofbill"
}]
},
"code" : {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
"code" : "Dummy"
}]
}
},
{
"sequence" : 5,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "pointoforigin"
}]
},
"code" : {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/PointOfOrigin",
"code" : "Dummy"
}]
}
},
{
"sequence" : 6,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "admtype"
}]
},
"code" : {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit",
"code" : "Dummy"
}]
}
},
{
"sequence" : 7,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "discharge-status"
}]
},
"code" : {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/PatDischargeStatus",
"code" : "11"
}]
}
},
{
"sequence" : 8,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "drg"
}]
},
"code" : {
"coding" : [{
"system" : "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software",
"code" : "Dummy"
}]
}
},
{
"sequence" : 9,
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "medicalrecordnumber"
}]
},
"valueString" : "1234-234-1243-12345678901m"
},
{
"sequence" : 10,
"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",
"code" : "principal"
}]
}],
"onAdmission": {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/PresentOnAdmissionIndicator",
"code" : "Y"
}]
}
}],
"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"
}
]
}
}
],
"insurance" : [{
"focal" : true,
"coverage" : {
"reference" : "Coverage/c4bb-Coverage"
}
}],
"item" : [{
"sequence" : 1,
"revenue" : {
"coding" : [{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0324"
}]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "99231"
}
]
},
"modifier" : [{
"coding" : [{
"system" : "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "A1"
}]
}],
"quantity": {
"value": 2,
"unit": "services"
},
"noteNumber": [1],
"adjudication" : [
{
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code" : "adjustmentreason"
}]
},
"reason" : {
"coding" : [{
"system" : "https://x12.org/codes/claim-adjustment-reason-codes",
"code" : "21"
}]
}
},
{
"category" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code" : "allowedunits"
}]
},
"value" : 2
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
],
"text" : "The total submitted amount for the claim or group or line item."
},
"amount" : {
"value" : 84.4,
"currency" : "USD"
}
}
]
}],
"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://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" : "adjustmentreason"
}]
},
"reason" : {
"coding" : [{
"system" : "https://x12.org/codes/claim-adjustment-reason-codes",
"code" : "21"
}]
}
}],
"total": [
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code": "paidtoprovider"
}
],
"text": "Payment Amount"
},
"amount": {
"value": 620,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
],
"text": "Submitted Amount"
},
"amount": {
"value": 2650,
"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"
}
]
},
"date" : "2017-05-23"
},
"processNote": [{
"text": "Note explanatory text"
}]
},
"request": {
"method": "PUT",
"url": "ExplanationOfBenefit/c4bb-EOBInpatient"
}
},
{
"resource": {
"resourceType": "ExplanationOfBenefit",
"id": "c4bb-EOBOutpatient",
"meta": {
"lastUpdated": "2019-12-12T09:14:11+00:00",
"profile": [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.0.0"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"c4bb-EOBOutpatient\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ExplanationOfBenefit "c4bb-EOBOutpatient" Updated "2019-12-12 09:14:11+0000" (Language "en-US") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Outpatient-Institutional.html\">C4BB ExplanationOfBenefit Outpatient Institutional (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>subType</b>: Outpatient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBInstitutionalClaimSubType.html\">C4BB Institutional Claim SubType Code System</a>#outpatient)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-888.html\">Patient/888</a> " TEST"</p><p><b>billablePeriod</b>: 2019-01-01 --> 2019-10-31</p><p><b>created</b>: 2019-11-02 12:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-c4bb-Organization.html\">Organization/c4bb-Organization: Organization C4BB</a> "Organization C4BB"</p><p><b>provider</b>: <a href=\"Organization-c4bb-Organization.html\">Organization/c4bb-Organization: Orange Medical Group</a> "Orange Medical Group"</p><p><b>outcome</b>: partial</p><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Organization-c4bb-Organization.html\">Organization/c4bb-Organization</a> "Orange Medical Group"</td><td>Rendering provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimCareTeamRole.html\">C4BB Claim Care Team Role Code System</a>#rendering)</span></td><td>Oncology Clinical Nurse Specialist <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (provider-taxonomy#364SX0200X)</span></td></tr></table><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#clmrecvddate)</span></p><p><b>timing</b>: 2019-11-30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Type of Bill <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#typeofbill)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCTypeOfBill.html\">AHA NUBC Type Of Bill Codes</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Point Of Origin <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#pointoforigin)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPointOfOriginNonnewborn.html\">AHA NUBC Point of Origin for Non-newborn</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Admission Type <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#admtype)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPriorityTypeOfAdmitOrVisit.html\">AHA NUBC Priority (Type) of Admission or Visit</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Discharge Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#discharge-status)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCPatientDischargeStatus.html\">AHA NUBC Patient Discharge Status Codes</a>#Dummy)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Medical Record Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#medicalrecordnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901m</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Patient Account Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#patientaccountnumber)</span></p><p><b>value</b>: 1234-234-1243-12345678901a</p></blockquote><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td>Concussion w LOC of 30 minutes or less, init <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.0X1A)</span></td><td>Patient Reason for Visit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimDiagnosisType.html\">C4BB Claim Diagnosis Type Code System</a>#patientreasonforvisit)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-c4bb-Coverage.html\">Coverage/c4bb-Coverage</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td></tr><tr><td>*</td><td>1</td><td>Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#Dummy)</span></td><td>Not Applicable <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-data-absent-reason.html\">DataAbsentReason</a>#not-applicable)</span></td><td>2019-11-02</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidbypatient)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>620</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>2650</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidbypatient)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code": "uc"
}
]
},
"system": "https://www.xxxplan.com/fhir/EOBIdentifier",
"value": "AW123412341234123412341234123412"
}
],
"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/888"
},
"billablePeriod": {
"start": "2019-01-01",
"end": "2019-10-31"
},
"created": "2019-11-02T00:00:00+00:00",
"insurer": {
"reference": "Organization/c4bb-Organization",
"display": "Organization C4BB"
},
"provider": {
"reference": "Organization/c4bb-Organization",
"display": "Orange Medical Group"
},
"related": [{
"relationship": {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code" : "prior"
}]
},
"reference": {
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123413"
}
}],
"outcome": "partial",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Organization/c4bb-Organization"
},
"role": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
"code": "rendering",
"display": "Rendering provider"
}
]
},
"qualification": {
"coding": [
{
"system": "http://nucc.org/provider-taxonomy",
"code": "364SX0200X",
"display": "Oncology Clinical Nurse Specialist"
}
]
}
}
],
"supportingInfo": [
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "clmrecvddate"
}
]
},
"timingDate": "2019-11-30"
},
{
"sequence": 3,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "typeofbill"
}
]
},
"code": {
"coding": [
{
"system": "https://www.nubc.org/CodeSystem/TypeOfBill",
"code": "Dummy"
}
]
}
},
{
"sequence": 4,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code": "pointoforigin"