CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft
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
| Page standards status: Informative |
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="EOBOral2"/>
<meta>
<lastUpdated value="2021-10-28T10:23:00-05:00"/>
<profile
value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.1.0-snapshot1"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit EOBOral2</b></p><a name="EOBOral2"> </a><a name="hcEOBOral2"> </a><a name="EOBOral2-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2021-10-28 10:23:00-0500; Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Oral.html">C4BB ExplanationOfBenefit Oralversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Unique Claim ID/210300012</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type oral}">Oral</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">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)</a></p><p><b>billablePeriod</b>: 2021-10-01 --> 2021-10-31</p><p><b>created</b>: 2021-10-28 10:23:00-0500</p><p><b>insurer</b>: <a href="Organization-DentalPayer1.html">XXX Health Plan</a></p><p><b>provider</b>: <a href="Practitioner-PractitionerDentalProvider1.html">XXX Dental Plan</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Claim Received Date</span></p><p><b>timing</b>: 2021-03-18</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType servicefacility}">Service Facility</span></p><p><b>value</b>: <a href="Organization-ProviderOrganization1.html">Organization Orange Medical Group</a></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientaccountnumber}">Patient Account Number</span></p><p><b>value</b>: PATIENTACCTNO3</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType additionalbodysite}">Additional Body Site</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem 1}">1</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType additionalbodysite}">Additional Body Site</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem 2}">2</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Coverage-CoverageDental1.html">Coverage: 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</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>informationSequence</b>: 6, 7, 9, 10, 11</p><p><b>productOrService</b>: <span title="Codes:{http://www.ada.org/cdt D0220}">Intraoral - periapical first radiographic image</span></p><p><b>serviced</b>: 2021-10-28</p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">Office</span></p><p><b>bodySite</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem 10}">Upper right quadrant</span></p><p><b>subSite</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes O}">Occlusal</span>, <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes I}">Incisal</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></p><p><b>reason</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>150</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator renderingnetworkstatus}">Rendering Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}">Billing Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>150</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}">Benefit Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>110</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication discount}">Discount Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>40</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}">Amount Paid to Provider</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>100</td><td>United States dollar</td></tr></table></blockquote></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
<code value="uc"/>
</coding>
</type>
<system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
<value value="210300012"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="oral"/>
</coding>
<text value="Oral"/>
</type>
<use value="claim"/>
<patient>🔗
<reference value="Patient/Patient2"/>
</patient>
<billablePeriod>
<start value="2021-10-01"/>
<end value="2021-10-31"/>
</billablePeriod>
<created value="2021-10-28T10:23:00-05:00"/>
<insurer>🔗
<reference value="Organization/DentalPayer1"/>
<display value="XXX Health Plan"/>
</insurer>
<provider>🔗
<reference value="Practitioner/PractitionerDentalProvider1"/>
<display value="XXX Dental Plan"/>
</provider>
<outcome value="complete"/>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="clmrecvddate"/>
</coding>
</category>
<timingDate value="2021-03-18"/>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="servicefacility"/>
</coding>
</category>
<valueReference>🔗
<reference value="Organization/ProviderOrganization1"/>
</valueReference>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="patientaccountnumber"/>
</coding>
</category>
<valueString value="PATIENTACCTNO3"/>
</supportingInfo>
<supportingInfo>
<sequence value="9"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="additionalbodysite"/>
</coding>
</category>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
<code value="1"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="10"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="additionalbodysite"/>
</coding>
</category>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
<code value="2"/>
</coding>
</code>
</supportingInfo>
<insurance>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/CoverageDental1"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<informationSequence value="6"/>
<informationSequence value="7"/>
<informationSequence value="9"/>
<informationSequence value="10"/>
<informationSequence value="11"/>
<productOrService>
<coding>
<system value="http://www.ada.org/cdt"/>
<code value="D0220"/>
<display value="Intraoral - periapical first radiographic image"/>
</coding>
</productOrService>
<servicedDate value="2021-10-28"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
<display value="Office"/>
</coding>
</locationCodeableConcept>
<bodySite>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem"/>
<code value="10"/>
<display value="Upper right quadrant"/>
</coding>
</bodySite>
<subSite>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes"/>
<code value="O"/>
</coding>
</subSite>
<subSite>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes"/>
<code value="I"/>
</coding>
</subSite>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="benefitpaymentstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="150"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="renderingnetworkstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="benefitpaymentstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
<code value="billingnetworkstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</reason>
</adjudication>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
<text value="Submitted Amount"/>
</category>
<amount>
<value value="150"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
<text value="Benefit Amount"/>
</category>
<amount>
<value value="110"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="discount"/>
</coding>
<text value="Discount Amount"/>
</category>
<amount>
<value value="40"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
<code value="paidtoprovider"/>
</coding>
<text value="Amount Paid to Provider"/>
</category>
<amount>
<value value="100"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0-snapshot1 based on FHIR 4.0.1. Generated 2024-07-27
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