CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot
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 
{
"resourceType" : "ExplanationOfBenefit",
"id" : "EOBOral2",
"meta" : {
"lastUpdated" : "2021-10-28T10:23:00-05:00",
"profile" : [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative</b></p><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\">Resource \"EOBOral2\" Updated \"2021-10-28T15:23:00Z\" (Language \"en-US\") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Oral.html\">C4BB ExplanationOfBenefit Oral (version 1.2.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: 210300012</p><p><b>status</b>: active</p><p><b>type</b>: Oral <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#oral)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Patient/Patient1</a> \" EXAMPLE1\"</p><p><b>billablePeriod</b>: 2021-10-01 --> 2021-10-31</p><p><b>created</b>: 2021-10-28T10:23:00-05:00</p><p><b>insurer</b>: <a href=\"Organization-OrganizationDentalPayer1.html\">Organization/OrganizationDentalPayer1: XXX Health Plan</a> \"INSURANCE COMPANY XYZ\"</p><p><b>provider</b>: <a href=\"Practitioner-PractitionerDentalProvider1.html\">Practitioner/PractitionerDentalProvider1: XXX Dental Plan</a> \" SCHMIDT\"</p><p><b>outcome</b>: complete</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Billing Network Contracting Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#billingnetworkcontractingstatus)</span></p><p><b>code</b>: Contracted <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#contracted)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Performing Network Contracting Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#performingnetworkcontractingstatus)</span></p><p><b>code</b>: Contracted <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#contracted)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#clmrecvddate)</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>: Service Facility <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#servicefacility)</span></p><p><b>value</b>: <a href=\"Organization-OrganizationProvider1.html\">Organization/OrganizationProvider1</a> \"Provider 1\"</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Patient Account Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#patientaccountnumber)</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>: Additional Body Site <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#additionalbodysite)</span></p><p><b>code</b>: 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAUniversalNumberingSystem.html\">American Dental Association Universal Numbering System</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: Additional Body Site <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#additionalbodysite)</span></p><p><b>code</b>: 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAUniversalNumberingSystem.html\">American Dental Association Universal Numbering System</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</p><p><b>category</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-CoverageDental1.html\">Coverage/CoverageDental1</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>: Intraoral - periapical first radiographic image <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADADentalProcedureCode.html\">ADA Code on Dental Procedures and Nomenclature</a>#D0220)</span></p><p><b>serviced</b>: 2021-10-28</p><p><b>location</b>: Office <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#11)</span></p><p><b>bodySite</b>: Upper right quadrant <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAAreaOfOralCavitySystem.html\">American Dental Association Area of Oral Cavity System</a>#10)</span></p><p><b>subSite</b>: Occlusal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSurfaceCodes.html\">US Surface Codes System</a>#O)</span>, Incisal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSurfaceCodes.html\">US Surface Codes System</a>#I)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Discount Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#discount)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount Paid to Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#paidtoprovider)</span></p></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}
]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "210300012"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}
],
"text" : "Oral"
},
"use" : "claim",
"patient" : {
"reference" : "Patient/Patient1"
},
"billablePeriod" : {
"start" : "2021-10-01",
"end" : "2021-10-31"
},
"created" : "2021-10-28T10:23:00-05:00",
"insurer" : {
"reference" : "Organization/OrganizationDentalPayer1",
"display" : "XXX Health Plan"
},
"provider" : {
"reference" : "Practitioner/PractitionerDentalProvider1",
"display" : "XXX Dental Plan"
},
"outcome" : "complete",
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "billingnetworkcontractingstatus"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "contracted"
}
]
}
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "performingnetworkcontractingstatus"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "contracted"
}
]
}
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate"
}
]
},
"timingDate" : "2021-03-18"
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "servicefacility"
}
]
},
"valueReference" : {
"reference" : "Organization/OrganizationProvider1"
}
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "patientaccountnumber"
}
]
},
"valueString" : "PATIENTACCTNO3"
},
{
"sequence" : 9,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "additionalbodysite"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
"code" : "1"
}
]
}
},
{
"sequence" : 10,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "additionalbodysite"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
"code" : "2"
}
]
}
},
{
"sequence" : 11,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/CoverageDental1"
}
}
],
"item" : [
{
"sequence" : 1,
"informationSequence" : [
6,
7,
9,
10,
11
],
"productOrService" : {
"coding" : [
{
"system" : "https://www.ada.org/en/publications/cdt",
"code" : "D0220",
"display" : "Intraoral - periapical first radiographic image"
}
]
},
"servicedDate" : "2021-10-28",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11",
"display" : "Office"
}
]
},
"bodySite" : {
"coding" : [
{
"system" : "https://ada.org/OralCavityCode-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
"code" : "10",
"display" : "Upper right quadrant"
}
]
},
"subSite" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes",
"code" : "O"
}
]
},
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes",
"code" : "I"
}
]
}
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 150,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 150,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
],
"text" : "Benefit Amount"
},
"amount" : {
"value" : 110,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "discount"
}
],
"text" : "Discount Amount"
},
"amount" : {
"value" : 40,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
],
"text" : "Amount Paid to Provider"
},
"amount" : {
"value" : 100,
"currency" : "USD"
}
}
]
}
IG © 2021+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.2.0 based on FHIR 4.0.1. Generated 2021-12-06
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