C4BBExplanationOfBenefitOutpatientInstitutionalBasis

C4BB ExplanationOfBenefit Outpatient Institutional Basis

activeCARIN Blue Button2.2.0resource48 key elements

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services. The basis profile does not have requirements for financial data.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional-Basis
ID
C4BB-ExplanationOfBenefit-Outpatient-Institutional-Basis
Type
Base Definition
C4BB-ExplanationOfBenefit
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
identifier
S
subType
S1+
created
S
careTeam.role
1+
:clmrecvddate0..1
S
Claim received date
supportingInfo.category
S
supportingInfo.timing[x]
date
S1+
:typeofbill0..1
S
Type of bill
supportingInfo.category
S
supportingInfo.code
S1+
:pointoforigin0..1
S
Point of origin for admission or visit
supportingInfo.category
S
supportingInfo.code
S1+
:admtype0..1
S
Admission type
supportingInfo.category
S
supportingInfo.code
S1+
:discharge-status0..1
S
Discharge status
supportingInfo.category
S
supportingInfo.code
S1+
:medicalrecordnumber0..1
S
Medical record number
supportingInfo.value[x]
1+
:valueString1..1
string
S1+
:patientaccountnumber0..1
S
Patient account number
supportingInfo.value[x]
1+
:valueString1..1
string
S1+
diagnosis
1+
diagnosis.diagnosis[x]
CodeableConcept
S
diagnosis.type1..1
S1+
item.revenue
S
item.productOrService
S
item.modifier
S
item.serviced[x]
date
S1+
item.quantity
S
item.adjudication
S
:adjustmentreason0..*
S
Reason codes used to interpret the Non-Covered Amount (92)
item.adjudication.reason
S1+
:allowedunits0..1
S
The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
item.adjudication.value
S1+
adjudication
BackboneElement
S1+
adjudication.category
S
:billingnetworkstatus0..1
S
Billing provider networking status
adjudication.reason
S1+
:benefitpaymentstatus1..1
S1+
Indicates the in network or out of network payment status of the claim. (142)
adjudication.reason
S1+
:adjustmentreason0..*
S
Reason codes used to interpret the Non-Covered Amount (92)
adjudication.reason
S1+
payment.date
S
processNote.text
S