HL7.FHIR.US.CARIN-BB\EOBOral1a

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot

This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOBOral1a

Generated Narrative

Resource "EOBOral1a" Updated "2021-03-18T15:23:00Z" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Oral (version 1.2.0)

identifier: Unique Claim ID: 210300002

status: active

type: Oral (Claim Type Codes#oral)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2021-03-01 --> 2021-03-31

created: 2021-03-18T10:23:00-05:00

insurer: Organization/OrganizationDentalPayer1: XXX Health Plan "INSURANCE COMPANY XYZ"

provider: Practitioner/PractitionerDentalProvider1: XXX Dental Plan " SCHMIDT"

outcome: complete

supportingInfo
sequence: 1
category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)
code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo
sequence: 2
category: Performing Network Contracting Status (C4BB Supporting Info Type#performingnetworkcontractingstatus)
code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo
sequence: 3
category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)
timing: 2021-03-18

supportingInfo
sequence: 4
category: Service Facility (C4BB Supporting Info Type#servicefacility)
value: Organization/OrganizationProvider1 "Provider 1"

supportingInfo
sequence: 5
category: Patient Account Number (C4BB Supporting Info Type#patientaccountnumber)
value: PATIENTACCTNO3

supportingInfo
sequence: 6
category: In Network (C4BB Payer Adjudication Status#innetwork)

Diagnoses

-

Sequence

Diagnosis[x]

Type

*

1

Encounter for dental examination and cleaning with abnormal findings (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#Z01.21)

Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-

Focal

Coverage

*

true

Coverage/CoverageDental1

item
sequence: 1
productOrService: Prophylaxis - Adult (ADA Code on Dental Procedures and Nomenclature#D1110)
serviced: 2021-03-18
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
adjudication
category: In Network (C4BB Payer Adjudication Status#innetwork)

item
sequence: 2
productOrService: Periodic oral evaluation (ADA Code on Dental Procedures and Nomenclature#D0120)
serviced: 2021-03-18
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
adjudication
category: In Network (C4BB Payer Adjudication Status#innetwork)

total
category: Submitted Amount (Adjudication Value Codes#submitted)

total
category: Benefit Amount (Adjudication Value Codes#benefit)

total
category: Discount Amount (C4BB Adjudication#discount)

total
category: Amount Paid to Provider (C4BB Adjudication#paidtoprovider)