CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.2.0 - STU 2 Pre-Publish United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.2.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Example ExplanationOfBenefit: EOBOral1a

Generated Narrative

Resource "EOBOral1a" Updated "2021-03-18 10:23:00-0500" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Oral (version 1.2.0)

identifier: Unique Claim ID: 210300002

status: active

type: Oral (Claim Type Codes#oral)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2021-03-01 --> 2021-03-31

created: 2021-03-18 10:23:00-0500

insurer: Organization/OrganizationDentalPayer1: XXX Health Plan "INSURANCE COMPANY XYZ"

provider: Practitioner/PractitionerDentalProvider1: XXX Dental Plan " SCHMIDT"

outcome: complete

supportingInfo

sequence: 1

category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)

code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo

sequence: 2

category: Performing Network Contracting Status (C4BB Supporting Info Type#performingnetworkcontractingstatus)

code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo

sequence: 3

category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)

timing: 2021-03-18

supportingInfo

sequence: 4

category: Service Facility (C4BB Supporting Info Type#servicefacility)

value: Organization/OrganizationProvider1 "Provider 1"

supportingInfo

sequence: 5

category: Patient Account Number (C4BB Supporting Info Type#patientaccountnumber)

value: PATIENTACCTNO3

supportingInfo

sequence: 6

category: In Network (C4BB Payer Adjudication Status#innetwork)

Diagnoses

-SequenceDiagnosis[x]Type
*1Encounter 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)

Insurances

-FocalCoverage
*trueCoverage/CoverageDental1

item

sequence: 1

productOrService: Prophylaxis - Adult (ADA Code on Dental Procedures and Nomenclature#D1110)

serviced: 2021-03-18

location: Office (CMS Place of Service Codes (POS)#11)

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)

adjudication

category: In Network (C4BB Payer Adjudication Status#innetwork)

item

sequence: 2

productOrService: Periodic oral evaluation (ADA Code on Dental Procedures and Nomenclature#D0120)

serviced: 2021-03-18

location: Office (CMS Place of Service Codes (POS)#11)

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)

adjudication

category: In Network (C4BB Payer Adjudication Status#innetwork)

total

category: Submitted Amount (Adjudication Value Codes#submitted)

total

category: Benefit Amount (Adjudication Value Codes#benefit)

total

category: Discount Amount (C4BB Adjudication#discount)

total

category: Amount Paid to Provider (C4BB Adjudication#paidtoprovider)

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "EOBOral1a"
meta.lastUpdated "2021-03-18T10:23:00-05:00"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0"
language "en-US"
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].type.coding[0].code #uc
identifier[0].system "https://www.xxxplan.com/fhir/EOBIdentifier"
identifier[0].value 210300002
status "active"
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.coding[0].code #oral
type.text "Oral"
use "claim"
patient.reference "Patient/Patient1"
billablePeriod.start "2021-03-01"
billablePeriod.end "2021-03-31"
created "2021-03-18T10:23:00-05:00"
insurer.reference "Organization/OrganizationDentalPayer1"
insurer.display "XXX Health Plan"
provider.reference "Practitioner/PractitionerDentalProvider1"
provider.display "XXX Dental Plan"
outcome "complete"
supportingInfo[0].sequence 1
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[1].sequence 2
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].category.coding[0].code #performingnetworkcontractingstatus
supportingInfo[1].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[1].code.coding[0].code #contracted
supportingInfo[2].sequence 3
supportingInfo[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[2].category.coding[0].code #clmrecvddate
supportingInfo[2].timingDate "2021-03-18"
supportingInfo[3].sequence 4
supportingInfo[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[3].category.coding[0].code #servicefacility
supportingInfo[3].valueReference.reference "Organization/OrganizationProvider1"
supportingInfo[4].sequence 5
supportingInfo[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[4].category.coding[0].code #patientaccountnumber
supportingInfo[4].valueString "PATIENTACCTNO3"
supportingInfo[5].sequence 6
supportingInfo[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[5].category.coding[0].code #innetwork
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #Z01.21
diagnosis[0].diagnosisCodeableConcept.coding[0].display "Encounter for dental examination and cleaning with abnormal findings"
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].type[0].coding[0].code #principal
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageDental1"
item[0].sequence 1
item[0].productOrService.coding[0].system "http://ada.org/cdt"
item[0].productOrService.coding[0].code #D1110
item[0].productOrService.coding[0].display "Prophylaxis - Adult"
item[0].servicedDate "2021-03-18"
item[0].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[0].locationCodeableConcept.coding[0].code #11
item[0].locationCodeableConcept.coding[0].display "Office"
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].amount.value 190
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[0].adjudication[1].category.coding[0].code #innetwork
item[1].sequence 2
item[1].productOrService.coding[0].system "http://ada.org/cdt"
item[1].productOrService.coding[0].code #D0120
item[1].productOrService.coding[0].display "Periodic oral evaluation"
item[1].servicedDate "2021-03-18"
item[1].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[1].locationCodeableConcept.coding[0].code #11
item[1].locationCodeableConcept.coding[0].display "Office"
item[1].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[0].category.coding[0].code #submitted
item[1].adjudication[0].amount.value 220
item[1].adjudication[0].amount.currency #USD
item[1].adjudication[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
item[1].adjudication[1].category.coding[0].code #innetwork
total[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[0].category.coding[0].code #submitted
total[0].category.text "Submitted Amount"
total[0].amount.value 410
total[0].amount.currency #USD
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.coding[0].code #benefit
total[1].category.text "Benefit Amount"
total[1].amount.value 350
total[1].amount.currency #USD
total[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[2].category.coding[0].code #discount
total[2].category.text "Discount Amount"
total[2].amount.value 60
total[2].amount.currency #USD
total[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[3].category.coding[0].code #paidtoprovider
total[3].category.text "Amount Paid to Provider"
total[3].amount.value 350
total[3].amount.currency #USD