CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2
US
This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "EOBOral1" Updated "2021-03-18 10:23:00-0500" (Language "en-US")
identifier: Unique Claim ID: 210300002
status: active
type: Oral (Claim Type Codes#oral)
use: claim
patient: Patient/Patient2 " TEST"
billablePeriod: 2021-03-01 --> 2021-03-31
created: 2021-03-18 10:23:00-0500
insurer: Organization/DentalPayer1: XXX Health Plan "INSURANCE COMPANY XYZ"
provider: Practitioner/PractitionerDentalProvider1: XXX Dental Plan " SCHMIDT"
outcome: complete
supportingInfo
sequence: 3
category: Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)
timing: 2021-03-18
supportingInfo
sequence: 4
category: Service Facility (C4BB Supporting Info Type Code System#servicefacility)
value: Organization/ProviderOrganization1 "Orange Medical Group"
supportingInfo
sequence: 5
category: Patient Account Number (C4BB Supporting Info Type Code System#patientaccountnumber)
value: PATIENTACCTNO3
| - | 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) |
| - | Focal | Coverage |
| * | true | Coverage/CoverageDental1 |
item
sequence: 1
productOrService: Prophylaxis - Adult (Code on Dental Procedures and Nomenclature#D1110)
serviced: 2021-03-18
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 190 USD
item
sequence: 2
productOrService: Periodic oral evaluation (Code on Dental Procedures and Nomenclature#D0120)
serviced: 2021-03-18
location: Office (CMS Place of Service Codes (POS)#11)
adjudication
category: Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)
reason: In Network (C4BB Payer Adjudication Status Code System#innetwork)
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 220 USD
| - | Category | Reason |
| * | Rendering Network Status (C4BB Adjudication Discriminator Code System#renderingnetworkstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
| * | Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
| * | Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus) | In Network (C4BB Payer Adjudication Status Code System#innetwork) |
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 410 USD
total
category: Benefit Amount (Adjudication Value Codes#benefit)
Amounts
- Value Currency * 350 USD
total
category: Discount Amount (C4BB Adjudication Code System#discount)
Amounts
- Value Currency * 60 USD
total
category: Amount Paid to Provider (C4BB Adjudication Code System#paidtoprovider)
Amounts
- Value Currency * 350 USD
Instance: EOBOral1
InstanceOf: ExplanationOfBenefit
Title: "EOB Oral Example 1"
Description: "EOB Oral Example 1"
Usage: #example
* meta.lastUpdated = "2021-03-18T10:23:00-05:00"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.0.0"
* language = #en-US
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc
* identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier"
* identifier.value = "210300002"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#oral
* text = "Oral"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2021-03-01"
* billablePeriod.end = "2021-03-31"
* created = "2021-03-18T10:23:00-05:00"
* insurer = Reference(DentalPayer1) "XXX Health Plan"
* provider = Reference(PractitionerDentalProvider1) "XXX Dental Plan"
* outcome = #complete
* supportingInfo[0].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2021-03-18"
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#servicefacility
* supportingInfo[=].valueReference = Reference(ProviderOrganization1)
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientaccountnumber
* supportingInfo[=].valueString = "PATIENTACCTNO3"
* diagnosis.sequence = 1
* diagnosis.diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#Z01.21 "Encounter for dental examination and cleaning with abnormal findings"
* diagnosis.type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal
* insurance.focal = true
* insurance.coverage = Reference(CoverageDental1)
* item[0].sequence = 1
* item[=].productOrService = http://ada.org/cdt#D1110 "Prophylaxis - Adult"
* item[=].servicedDate = "2021-03-18"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* item[=].adjudication[=].amount.value = 190
* item[=].adjudication[=].amount.currency = #USD
* item[+].sequence = 2
* item[=].productOrService = http://ada.org/cdt#D0120 "Periodic oral evaluation"
* item[=].servicedDate = "2021-03-18"
* item[=].locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* item[=].adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* item[=].adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* item[=].adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* item[=].adjudication[=].amount.value = 220
* item[=].adjudication[=].amount.currency = #USD
* adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#renderingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* total[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* total[=].category.text = "Submitted Amount"
* total[=].amount.value = 410
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
* text = "Benefit Amount"
* total[=].amount.value = 350
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#discount
* text = "Discount Amount"
* total[=].amount.value = 60
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* text = "Amount Paid to Provider"
* total[=].amount.value = 350
* total[=].amount.currency = #USD
IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#2.0.0 based on FHIR 4.0.1. Generated 2022-11-28
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