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: EOBOral2

Generated Narrative

Resource "EOBOral2" Updated "2021-10-28T15:23:00Z" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Oral (version 1.2.0)

identifier: Unique Claim ID: 210300012

status: active

type: Oral (Claim Type Codes#oral)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

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

created: 2021-10-28T10:23:00-05:00

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: 8

category: Patient Account Number (C4BB Supporting Info Type#patientaccountnumber)

value: PATIENTACCTNO3

supportingInfo

sequence: 9

category: Additional Body Site (C4BB Supporting Info Type#additionalbodysite)

code: 1 (American Dental Association Universal Numbering System#1)

supportingInfo

sequence: 10

category: Additional Body Site (C4BB Supporting Info Type#additionalbodysite)

code: 2 (American Dental Association Universal Numbering System#2)

supportingInfo

sequence: 11

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

Insurances

-FocalCoverage
*trueCoverage/CoverageDental1

item

sequence: 1

informationSequence: 6, 7, 9, 10, 11

productOrService: Intraoral - periapical first radiographic image (ADA Code on Dental Procedures and Nomenclature#D0220)

serviced: 2021-10-28

location: Office (CMS Place of Service Codes (POS)#11)

bodySite: Upper right quadrant (American Dental Association Area of Oral Cavity System#10)

subSite: Occlusal (US Surface Codes System#O), Incisal (US Surface Codes System#I)

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)