Inpatient Institutional

Datasets

An inpatient institutional claim is a facility bill (UB-04) for a stay with an admission and a discharge: hospital, skilled nursing, rehabilitation, psychiatric. CARIN Blue Button STU 2.1.0 profiles it twice. The financial profile carries the amounts and is what Patient Access serves. Its parent, the Basis profile, is the same claim without amounts and is what Provider Access and Payer-to-Payer serve. You deliver one pair of files; Payerbox produces both forms.

Both files carry every column from Explanation of Benefit. This page lists what the inpatient profile adds and where it tightens a shared rule.

claims_inpatient

One row per inpatient claim.

Stay

The admission, the bill and the discharge. In FHIR these are supportingInfo entries, one per column, each tagged with its C4BBSupportingInfoType category.

• admission_date and discharge_date are one FHIR element, the admission period. CARIN requires the period on every inpatient claim, so admission_date is mandatory even when the bill covers only part of the stay. When a discharge_date is present, discharge_status should say how the stay ended.
• type_of_bill is the four-character code as it appears in FL 04, with the leading zero. The three digits after it are the facility type, the bill classification and the frequency.
• point_of_origin values differ for newborn admissions. When admission_type is 4 (newborn), send a code from the newborn point-of-origin set, and otherwise from the standard set; CARIN rejects the combination the other way around.
• A DRG is only meaningful with its grouper: drg_code 291 is a different diagnosis group under MS-DRG than under APR-DRG. Send drg_version whenever your system holds it.
• The NUBC code sets and the DRG groupers are licensed, so their value sets are linked to the IG rather than expanded here. Send the codes as your adjudication system holds them.

Care team

One column per role. The role is the column name, the value is the provider. Roles are bound to C4BBClaimInstitutionalCareTeamRole.

• On an institutional claim the billing_provider_npi from the shared columns must be an organization, the facility that billed. CARIN restricts the inpatient profile's provider to an Organization, so a row whose billing NPI resolves to a practitioner is rejected.
• CARIN fixes who each role can be: attending, referring and primary must resolve to a Practitioner, rendering to an Organization. Operating and other operating may be either. A role whose NPI is defined in the wrong dataset is reported.

Diagnoses

An inpatient claim carries a principal diagnosis, optionally an admitting diagnosis, up to twenty-four other diagnoses and external cause of injury codes. They travel as four positionally aligned ;-separated lists; the position is the diagnosis sequence.

• Exactly one position must be principal. Send the principal first: it makes the file readable, and the sequence numbers a member sees on the EOB start from it.
• The same code may appear twice when it is both the admitting and the principal diagnosis. Send both positions; they are distinct entries in FHIR.

Procedures

Inpatient procedures are ICD-10-PCS, one per position, aligned like the diagnoses.

Adjudication

The claim-level adjudication decisions that are not amounts.

• benefit_payment_status is mandatory on every inpatient claim. It answers how the member's benefits were applied, and can differ from billing_network_status: an out-of-network facility paid at in-network benefits for an emergency is outofnetwork for the provider and innetwork for the benefit.
• payment_date from the shared columns is must-support here. Send it whenever the claim was paid.

Amounts

The shared amount columns apply, with two inpatient rules.

• Totals are mandatory: at least one amount column on the claim row must be filled. Send every total your system holds; submitted_amount, eligible_amount, benefit_amount, paid_to_provider_amount and paid_by_patient_amount are the ones members look for.
• CARIN allows an institutional claim to carry its adjudication amounts either on the lines or on the claim, never both. Fill the amount columns on the lines when your system adjudicates line by line. Leave every line amount blank when the claim was priced as a whole, as with a DRG payment, and Payerbox publishes the claim row's totals as the claim-level adjudication too. A delivery with amounts on both the claim row and its lines is rejected.

Set by Payerbox

These profile elements have no column. Payerbox fixes them from the dataset or derives them from other columns.

claims_inpatient_lines

One row per revenue line. Every line carries a revenue code; a procedure code is present only where the facility billed one.

• service_code overrides the shared rule that every line needs one. Room and board, operating room time and most ancillary revenue lines carry no CPT or HCPCS. On such a line Payerbox fills the profile's mandatory procedure element with the not-applicable marker CARIN provides for exactly this case.
• service_date_start and service_date_end from the shared columns are optional here; the stay's dates live on the claim row. Send them where a line has its own dates, such as a single-day procedure inside a longer stay.
• quantity is what the facility billed, allowed_units what the payer allowed. Both are plain numbers; a room and board line for a six-day stay has quantity 6.
• The amount columns follow the claim-or-lines rule above: either every line in the claim carries its amounts, or none does.

These resources are served by Patient Access with amounts, and by Provider Access and Payer-to-Payer without them.