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 
<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|1.2.0"/>
</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><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>
</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/Patient1"/>
</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/OrganizationDentalPayer1"/>
<display value="XXX Health Plan"/>
</insurer>
<provider>
<reference value="Practitioner/PractitionerDentalProvider1"/>
<display value="XXX Dental Plan"/>
</provider>
<outcome value="complete"/>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="billingnetworkcontractingstatus"/>
</coding>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="performingnetworkcontractingstatus"/>
</coding>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
</coding>
</code>
</supportingInfo>
<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/OrganizationProvider1"/>
</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="https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL"/>
<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="https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL"/>
<code value="2"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="11"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</category>
</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="https://www.ada.org/en/publications/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="https://ada.org/OralCavityCode-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL"/>
<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://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="150"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</category>
</adjudication>
</item>
<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 © 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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