CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0-snapshot1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: BB-EOBOral2-nonfinancial

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit BB-EOBOral2-nonfinancial

Last updated: 2021-10-28 10:23:00-0500; Language: en-US

Profile: C4BB ExplanationOfBenefit Oral Basisversion: {0}2.1.0-snapshot1)

identifier: Unique Claim ID/210300012

status: Active

type: Oral

use: Claim

patient: 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.: 88800933501)

billablePeriod: 2021-10-01 --> 2021-10-31

created: 2021-10-28 10:23:00-0500

insurer: XXX Health Plan

provider: XXX Dental Plan

outcome: Processing Complete

supportingInfo

sequence: 3

category: Claim Received Date

timing: 2021-03-18

supportingInfo

sequence: 4

category: Service Facility

value: Organization Orange Medical Group

supportingInfo

sequence: 8

category: Patient Account Number

value: PATIENTACCTNO3

supportingInfo

sequence: 9

category: Additional Body Site

code: 1

supportingInfo

sequence: 10

category: Additional Body Site

code: 2

Insurances

-FocalCoverage
*trueCoverage: identifier = Member Number; status = active; type = dental care policy; subscriberId = 10300007; dependent = 01; relationship = Self; period = 2021-01-01 --> 2021-12-31; network = INSURANCE COMPANY XYZ - PRIME

item

sequence: 1

informationSequence: 6, 7, 9, 10, 11

productOrService: Intraoral - periapical first radiographic image

serviced: 2021-10-28

location: Office

bodySite: Upper right quadrant

subSite: Occlusal, Incisal

Adjudications

-CategoryReason
*Benefit Payment StatusIn Network

Adjudications

-CategoryReason
*Rendering Network StatusIn Network
*Benefit Payment StatusIn Network
*Billing Network StatusIn Network