CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: BB-EOBOral2-nonfinancial - XML Representation

Page standards status: Informative

Raw xml | Download


<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="BB-EOBOral2-nonfinancial"/>
  <meta>
    <lastUpdated value="2021-10-28T10:23:00-05:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis|2.1.0"/>
  </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 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 --&gt; 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 --&gt; 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>
  </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/Patient2"/>
  </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/DentalPayer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Practitioner/PractitionerDentalProvider1"/>
    <display value="XXX Dental Plan"/>
  </provider>
  <outcome value="complete"/>
  <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/ProviderOrganization1"/>
    </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="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
        <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="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
        <code value="2"/>
      </coding>
    </code>
  </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="http://www.ada.org/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="http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem"/>
        <code value="10"/>
        <display value="Upper right quadrant"/>
      </coding>
    </bodySite>
    <subSite>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"/>
        <code value="O"/>
      </coding>
    </subSite>
    <subSite>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"/>
        <code value="I"/>
      </coding>
    </subSite>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
          <code value="benefitpaymentstatus"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
          <code value="innetwork"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="renderingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
</ExplanationOfBenefit>