Locate the CARIN BB Outpatient Institutional EOB profile in the IG and note differences from the Inpatient Institutional profile, particularly around hospitalization dates (not required) and revenue code requirements.
Set EOB.type to the outpatient institutional claim type value and populate EOB.item entries with revenue codes (UB-04 revenue codes), HCPCS/CPT procedure codes, and service dates.
Populate EOB.diagnosis with ICD-10-CM diagnosis codes, including principal and other diagnosis type slices as defined by the CARIN BB value sets.
Include adjudication slices on EOB.item.adjudication and EOB.total for submitted, eligible, and benefit amounts, referencing the CARIN BB adjudication value set.
Reference a CARIN BB Coverage resource in EOB.insurance and a CARIN BB Patient in EOB.patient; ensure identifiers conform to CARIN BB identifier type slicing.
Run the FHIR $validate operation against the outpatient institutional profile canonical and verify the resource passes without errors on required must-support elements.
Known gotchas
The outpatient institutional profile does not require EOB.hospitalization, but if admission/discharge dates are known they should still be populated — omitting known data violates the must-support obligation.
HCPCS/CPT codes on EOB.item.productOrService must reference the value set specified in the profile; mixing code system URIs (e.g., using 'http://www.ama-assn.org/go/cpt' vs the CARIN-required URI) causes validation failures.
Conditional must-support elements (e.g., modifier codes, place of service) are required when the claim data contains them — implementers must not strip these fields during ETL from the payer's adjudication system.
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp