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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "BB-EOBOral2-nonfinancial"] ; #
fhir:meta [
fhir:lastUpdated [ fhir:v "2021-10-28T10:23:00-05:00"^^xsd:dateTime ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis|2.1.0"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis|2.1.0> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit BB-EOBOral2-nonfinancial</b></p><a name=\"BB-EOBOral2-nonfinancial\"> </a><a name=\"hcBB-EOBOral2-nonfinancial\"> </a><a name=\"BB-EOBOral2-nonfinancial-en-US\"> </a><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\">Last updated: 2021-10-28 10:23:00-0500; Language: en-US</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Oral-Basis.html\">C4BB ExplanationOfBenefit Oral Basisversion: null2.1.0)</a></p></div><p><b>identifier</b>: Unique Claim ID/210300012</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type oral}\">Oral</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-Patient2.html\">Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)</a></p><p><b>billablePeriod</b>: 2021-10-01 --> 2021-10-31</p><p><b>created</b>: 2021-10-28 10:23:00-0500</p><p><b>insurer</b>: <a href=\"Organization-DentalPayer1.html\">XXX Health Plan</a></p><p><b>provider</b>: <a href=\"Practitioner-PractitionerDentalProvider1.html\">XXX Dental Plan</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Claim Received Date</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>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType servicefacility}\">Service Facility</span></p><p><b>value</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization Orange Medical Group</a></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType patientaccountnumber}\">Patient Account Number</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>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType additionalbodysite}\">Additional Body Site</span></p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem 1}\">Permanent maxillary right third molar tooth</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType additionalbodysite}\">Additional Body Site</span></p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem 2}\">Permanent maxillary right second molar tooth</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-CoverageDental1.html\">Coverage: identifier = Member Number; status = active; type = dental care policy; subscriberId = 10300007; dependent = 01; relationship = Self; period = 2021-01-01 --> 2021-12-31; network = INSURANCE COMPANY XYZ - PRIME</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>: <span title=\"Codes:{http://www.ada.org/cdt D0220}\">Intraoral - periapical first radiographic image</span></p><p><b>serviced</b>: 2021-10-28</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}\">Office</span></p><p><b>bodySite</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem 10}\">Upper right quadrant</span></p><p><b>subSite</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes O}\">Occlusal</span>, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes I}\">Incisal</span></p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr></table></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator renderingnetworkstatus}\">Rendering Network Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}\">Billing Network Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr></table></div>"^^rdf:XMLLiteral
] ; #
fhir:identifier ( [
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "uc" ] ] ) ] ;
fhir:system [ fhir:v "https://www.xxxplan.com/fhir/EOBIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "210300012" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "oral" ] ] ) ;
fhir:text [ fhir:v "Oral" ]
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/Patient2" ]
] ; #
fhir:billablePeriod [
fhir:start [ fhir:v "2021-10-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-10-31"^^xsd:date ]
] ; #
fhir:created [ fhir:v "2021-10-28T10:23:00-05:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/DentalPayer1" ] ;
fhir:display [ fhir:v "XXX Health Plan" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Practitioner/PractitionerDentalProvider1" ] ;
fhir:display [ fhir:v "XXX Dental Plan" ]
] ; #
fhir:outcome [ fhir:v "complete"] ; #
fhir:supportingInfo ( [
fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "clmrecvddate" ] ] ) ] ;
fhir:timing [
a fhir:date ;
fhir:v "2021-03-18"^^xsd:date ]
] [
fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "servicefacility" ] ] ) ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Organization/ProviderOrganization1" ] ]
] [
fhir:sequence [ fhir:v "8"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "patientaccountnumber" ] ] ) ] ;
fhir:value [
a fhir:string ;
fhir:v "PATIENTACCTNO3" ]
] [
fhir:sequence [ fhir:v "9"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "additionalbodysite" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1" ] ] ) ]
] [
fhir:sequence [ fhir:v "10"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "additionalbodysite" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ] ] ) ]
] ) ; #
fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/CoverageDental1" ] ]
] ) ; #
fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
( fhir:informationSequence [ fhir:v "6"^^xsd:positiveInteger ] [ fhir:v "7"^^xsd:positiveInteger ] [ fhir:v "9"^^xsd:positiveInteger ] [ fhir:v "10"^^xsd:positiveInteger ] [ fhir:v "11"^^xsd:positiveInteger ] ) ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "http://www.ada.org/cdt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "D0220" ] ;
fhir:display [ fhir:v "Intraoral - periapical first radiographic image" ] ] ) ] ;
fhir:serviced [
a fhir:date ;
fhir:v "2021-10-28"^^xsd:date ] ;
fhir:location [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11" ] ;
fhir:display [ fhir:v "Office" ] ] ) ] ;
fhir:bodySite [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10" ] ;
fhir:display [ fhir:v "Upper right quadrant" ] ] ) ] ;
( fhir:subSite [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "O" ] ] ) ] [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ] ) ] ) ;
( fhir:adjudication [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ] ] )
] ) ; #
fhir:adjudication ( [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "renderingnetworkstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "billingnetworkstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ]
] ) . #
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2025-02-18
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