HL7.FHIR.US.CARIN-BB\EOB Oral Example 2

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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Oral Example 2

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBOral2" Updated "2021-10-28 10:23:00-0500" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Oral (version 2.0.0)

identifier: Unique Claim ID: 210300012

status: active

type: Oral (Claim Type Codes#oral)

use: claim

patient: Patient/Patient2 " TEST"

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

created: 2021-10-28 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: 8
category: Patient Account Number (C4BB Supporting Info Type Code System#patientaccountnumber)
value: PATIENTACCTNO3

supportingInfo
sequence: 9
category: Additional Body Site (C4BB Supporting Info Type Code System#additionalbodysite)
code: 1 (ADA Universal Tooth Designation System#1)

supportingInfo
sequence: 10
category: Additional Body Site (C4BB Supporting Info Type Code System#additionalbodysite)
code: 2 (ADA Universal Tooth Designation System#2)

Insurances

-

Focal

Coverage

*

true

Coverage/CoverageDental1

item
sequence: 1
informationSequence: 6, 7, 9, 10, 11
productOrService: Intraoral - periapical first radiographic image (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: 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
* 150 USD

Adjudications

-

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
* 150 USD

total
category: Benefit Amount (Adjudication Value Codes#benefit)
Amounts
- Value Currency
* 110 USD

total
category: Discount Amount (C4BB Adjudication Code System#discount)
Amounts
- Value Currency
* 40 USD

total
category: Amount Paid to Provider (C4BB Adjudication Code System#paidtoprovider)
Amounts
- Value Currency
* 100 USD

Notes:

Instance: EOBOral2
InstanceOf: ExplanationOfBenefit
Title: "EOB Oral Example 2"
Description: "EOB Oral Example 2"
Usage: #example
* meta.lastUpdated = "2021-10-28T10:23:00-05:00"
* 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 = "210300012"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#oral
  * text = "Oral"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2021-10-01"
* billablePeriod.end = "2021-10-31"
* created = "2021-10-28T10:23:00-05:00"
* 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 = 8
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#patientaccountnumber
* supportingInfo[=].valueString = "PATIENTACCTNO3"
* supportingInfo[+].sequence = 9
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#additionalbodysite
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem#1
* supportingInfo[+].sequence = 10
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#additionalbodysite
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem#2
* insurance.focal = true
* insurance.coverage = Reference(CoverageDental1)
* item.sequence = 1
* item.informationSequence[0] = 6
* item.informationSequence[+] = 7
* item.informationSequence[+] = 9
* item.informationSequence[+] = 10
* item.informationSequence[+] = 11
* item.productOrService = http://ada.org/cdt#D0220 "Intraoral - periapical first radiographic image"
* item.servicedDate = "2021-10-28"
* item.locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* item.bodySite = http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem#10 "Upper right quadrant"
* item.subSite[0] = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes#O
* item.subSite[+] = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes#I
* 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 = 150
* 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 = 150
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
  * text = "Benefit Amount"
* total[=].amount.value = 110
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#discount
  * text = "Discount Amount"
* total[=].amount.value = 40
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
  * text = "Amount Paid to Provider"
* total[=].amount.value = 100
* 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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