Professional NonClinician

Datasets

A professional claim is a CMS-1500 bill from a practitioner, group, supplier or transportation provider: office visits, surgery, therapy, durable medical equipment, ambulance. Vision claims use the same profile. CARIN Blue Button STU 2.1.0 profiles it twice: the financial profile with amounts for Patient Access, and its parent Basis profile without amounts for Provider Access and Payer-to-Payer. You deliver one pair of files.

Dataset	CARIN BB STU 2.1.0 target profile
`claims_professional`	C4BB ExplanationOfBenefit Professional NonClinician, served without amounts as Professional NonClinician Basis
`claims_professional_lines`	`ExplanationOfBenefit.item` of the same profile

Both files carry every column from Explanation of Benefit. This page lists what the professional profile adds and where it tightens a shared rule. The biggest difference from the institutional claims: adjudication happens on the lines. Every line carries its own amounts and its own benefit payment status, and the claim row carries only totals.

claims_professional

One row per professional claim.

Claim

Column	Required	Format / values	Example
`claim_type`	If vision	`vision` for a vision claim (`professional` assumed when empty) C4BBProfessionalAndNonClinicianClaimType	`vision`
`claim_received_date`	Recommended	date the payer received the claim	`2026-03-10`
`service_facility_npi`	If not the billing provider's place	10 digits; key from `organizations`; the facility where the service was rendered when it is neither the billing provider nor the patient's home	`9999999994`
`medical_record_number`	If available	the provider's medical record number on the claim	`MR-88213`
`patient_account_number`	If available	the provider's patient account number on the claim	`ACC-501377`

claim_type exists because CARIN serves vision claims through this profile with type = vision. A vision claim may leave service_code blank on its lines; a professional claim may not.
billing_provider_npi may resolve to either a Practitioner or an Organization here, unlike the institutional claims. A solo practitioner bills under their own NPI; a group or a supplier bills under the organization's.
service_facility_npi is a place, not a person: a hospital, nursing home, laboratory or shelter where the practitioner saw the patient. It must be defined in organizations.

Care team

One column per role, bound to C4BBClaimProfessionalAndNonClinicianCareTeamRole.

Column	Required	Format / values	Example
`rendering_provider_npi`	Recommended	10 digits; key from `practitioners`; who performed the service	`9999999991`
`rendering_provider_taxonomy`	If available	NUCC taxonomy code the rendering provider billed under Healthcare Provider Taxonomy	`207R00000X`
`referring_provider_npi`	If available	10 digits; key from `practitioners`	`9999999991`
`supervising_provider_npi`	If available	10 digits; key from `practitioners`
`primary_provider_npi`	If available	10 digits; key from `practitioners`
`purchased_service_provider_npi`	If available	10 digits; key from `practitioners` or `organizations`; the provider a service was purchased from, such as an outside laboratory

CARIN fixes that rendering, referring, supervising and primary must resolve to a Practitioner. Purchased service may be either.
rendering_provider_taxonomy becomes the care-team qualification, the specialty the claim was billed under. It can differ from the specialty in practitioners, so it is sent with the claim.

Diagnoses

Aligned ;-separated lists, the position being the diagnosis sequence. Lines point at these positions through diagnosis_sequences.

Column	Required	Format / values	Example
`diagnosis_codes`	Yes	ICD-10-CM codes, `;`-separated, up to twelve CDCICD910CMDiagnosisCodes	`E11.9;I10`
`diagnosis_types`	Yes	`principal`, `secondary`, aligned with `diagnosis_codes` C4BBClaimProfessionalAndNonClinicianDiagnosisType	`principal;secondary`
`diagnosis_code_system`	If not ICD-10-CM	`http://hl7.org/fhir/sid/icd-9-cm` for services before October 2015 (ICD-10-CM assumed when empty)

Exactly one position is principal, sent first. Every other position is secondary; the professional profile has no admitting, external cause or reason-for-visit types.

Network status

Column	Required	Format / values	Example
`billing_network_status`	Recommended	`innetwork`, `outofnetwork`; whether the billing provider had a contract with the plan on the date of service C4BBPayerProviderNetworkStatus	`innetwork`
`rendering_network_status`	Recommended	`innetwork`, `outofnetwork`; the same for the rendering provider	`innetwork`

The benefit payment status, mandatory on every line of a professional claim, is a line column. The claim row has no benefit payment status and no claim-level adjustment reasons; the profile puts both on the lines.

Transportation

For ambulance and other transportation claims. These four describe the whole trip and sit on the claim row; the pickup, drop-off and distance of each leg sit on the line. Payerbox links the claim-level entries to every line of the claim, which is what CARIN requires of transportation information.

Column	Required	Format / values	Example
`patient_weight_lb`	If ambulance	decimal, pounds	`160`
`ambulance_transport_reason`	If ambulance	one-letter X12 ambulance transport reason code C4BBAmbulanceTransportReasonCodes	`B`
`round_trip_purpose`	If a round trip	free text	`Dialysis and return home`
`stretcher_purpose`	If a stretcher	free text	`Patient unable to sit`

Amounts

The shared amount columns on the claim row become the claim totals, which are mandatory: at least one must be filled. The professional profile has no claim-level adjudication amounts, so the claim row's amounts are never anything but totals. Line amounts are mandatory too, see below.

Set by Payerbox

Element	Value
`type`	`professional`, or `vision` when `claim_type` says so
`use`	`claim`
`meta.profile`	the Professional NonClinician canonical with version `2.1.0`
`identifier.type`	`uc`
`insurance.focal`	`true` on the coverage from `coverage_id`
`careTeam.sequence`, `supportingInfo.sequence`, `diagnosis.sequence`, `item.informationSequence`	numbered from the columns and list positions

claims_professional_lines

One row per service line. Each line is adjudicated on its own, so each carries a place of service, a benefit payment status and its amounts.

Column	Required	Format / values	Example
`service_code`	Yes, blank only on vision	CPT or HCPCS code, with `service_code_system` AMACPTCMSHCPCSProcedureCodes	`99214`
`service_code_system`	If HCPCS	`https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets` (CPT, `http://www.ama-assn.org/go/cpt`, assumed when empty)
`modifier_codes`	If billed	CPT or HCPCS modifiers, `;`-separated, same system as `service_code` AMACPTCMSHCPCSModifiers	`25`
`service_date_start`	Yes	date the service began; CMS-1500 item 24A	`2026-03-05`
`service_date_end`	If a period	date the service ended; blank for a single-day service
`place_of_service`	Yes	two-digit CMS place-of-service code CMSPlaceofServiceCodes	`11`
`quantity`	Recommended	decimal; units, visits or miles billed on the line	`1`
`diagnosis_sequences`	If available	positions in the claim's `diagnosis_codes` this line was billed against, `;`-separated	`1;2`
`benefit_payment_status`	Yes	`innetwork`, `outofnetwork`, `other`; how this line was paid against the member's benefits C4BBPayerBenefitPaymentStatus	`innetwork`
`allowed_units`	If adjudicated	decimal; units the payer allowed	`1`
`adjustment_reason_code`	If reduced or denied	one CARC or RARC code explaining the noncovered amount X12 CARC and RARC	`97`
`adjustment_reason_system`	If RARC	`https://x12.org/codes/remittance-advice-remark-codes` (CARC, `https://x12.org/codes/claim-adjustment-reason-codes`, assumed when empty)
`pickup_location`	If ambulance	free text; where the patient was picked up on this leg	`Patient home; Anytown; NY 12345`
`dropoff_location`	If ambulance	free text; where the patient was dropped off on this leg	`Anytown Medical Group; Anytown; NY 12345`
`transport_distance_miles`	If ambulance	decimal, miles travelled on this leg	`21`
amount columns	Yes, at least one	line-level adjudication, one column per category

service_code is required on every professional line. Only a vision claim, marked by claim_type, may leave it blank, and Payerbox then publishes the not-applicable marker CARIN provides.
place_of_service is mandatory and drives whether the line was an office visit, a home visit, an ambulance run or a hospital service. Send the two-digit CMS code, not a description.
benefit_payment_status and at least one amount are mandatory on every line. A line with neither describes nothing and is rejected. A denied line carries submitted_amount, 0.00 in benefit_amount, the denied amount in noncovered_amount and the reason in adjustment_reason_code.
adjustment_reason_code is a single code here, not a list: the professional profile allows one adjustment reason per line. Where your system holds several, send the CARC that determined the adjustment.
The three transportation columns repeat per leg: an ambulance round trip is two lines, each with its own pickup, drop-off and distance. Send them only on transportation lines; a value on an office-visit line is rejected.

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