{ "resourceType" : "ExplanationOfBenefit", "id" : "EOBOral2", "meta" : { "lastUpdated" : "2021-10-28T10:23:00-05:00", "profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.2.0"] }, "language" : "en-US", "text" : { "status" : "generated", "div" : "

Generated Narrative: ExplanationOfBenefit EOBOral2

Last updated: 2021-10-28 10:23:00-0500; Language: en-US

Profile: C4BB ExplanationOfBenefit Oralversion: null2.2.0)

identifier: Unique Claim ID/210300012

status: Active

type: Oral

use: Claim

patient: 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.:\u00a088800933501)

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

created: 2021-10-28 10:23:00-0500

insurer: XXX Health Plan

provider: XXX Dental Plan

outcome: Processing Complete

supportingInfo

sequence: 3

category: Claim Received Date

timing: 2021-03-18

supportingInfo

sequence: 4

category: Service Facility

value: Organization Orange Medical Group

supportingInfo

sequence: 8

category: Patient Account Number

value: PATIENTACCTNO3

supportingInfo

sequence: 9

category: Additional Body Site

code: Permanent maxillary right third molar tooth

supportingInfo

sequence: 10

category: Additional Body Site

code: Permanent maxillary right second molar tooth

Insurances

-FocalCoverage
*trueCoverage: 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

item

sequence: 1

informationSequence: 6, 7, 9, 10, 11

productOrService: Intraoral - periapical first radiographic image

serviced: 2021-10-28

location: Office

bodySite: Upper right quadrant

subSite: Occlusal, Incisal

adjudication

category: Benefit Payment Status

reason: In Network

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*150United States dollar

Adjudications

-CategoryReason
*Rendering Network StatusIn Network
*Benefit Payment StatusIn Network
*Billing Network StatusIn Network

total

category: Submitted Amount

Amounts

-ValueCurrency
*150United States dollar

total

category: Benefit Amount

Amounts

-ValueCurrency
*110United States dollar

total

category: Discount Amount

Amounts

-ValueCurrency
*40United States dollar

total

category: Amount Paid to Provider

Amounts

-ValueCurrency
*100United States dollar
" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType", "code" : "uc" }] }, "system" : "https://www.example.com/fhir/EOBIdentifier", "value" : "210300012" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "version" : "1.0.1", "code" : "oral" }], "text" : "Oral" }, "use" : "claim", "patient" : { "reference" : "Patient/Patient2" }, "billablePeriod" : { "start" : "2021-10-01", "end" : "2021-10-31" }, "created" : "2021-10-28T10:23:00-05:00", "insurer" : { "reference" : "Organization/DentalPayer1", "display" : "XXX Health Plan" }, "provider" : { "reference" : "Practitioner/PractitionerDentalProvider1", "display" : "XXX Dental Plan" }, "outcome" : "complete", "supportingInfo" : [{ "sequence" : 3, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "clmrecvddate" }] }, "timingDate" : "2021-03-18" }, { "sequence" : 4, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "servicefacility" }] }, "valueReference" : { "reference" : "Organization/ProviderOrganization1" } }, { "sequence" : 8, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "patientaccountnumber" }] }, "valueString" : "PATIENTACCTNO3" }, { "sequence" : 9, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "additionalbodysite" }] }, "code" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem", "code" : "1" }] } }, { "sequence" : 10, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType", "code" : "additionalbodysite" }] }, "code" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem", "code" : "2" }] } }], "insurance" : [{ "focal" : true, "coverage" : { "reference" : "Coverage/CoverageDental1" } }], "item" : [{ "sequence" : 1, "informationSequence" : [6, 7, 9, 10, 11], "productOrService" : { "coding" : [{ "system" : "http://www.ada.org/cdt", "code" : "D0220", "display" : "Intraoral - periapical first radiographic image" }] }, "servicedDate" : "2021-10-28", "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "11", "display" : "Office" }] }, "bodySite" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem", "code" : "10", "display" : "Upper right quadrant" }] }, "subSite" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes", "code" : "O" }] }, { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes", "code" : "I" }] }], "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "benefitpaymentstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "innetwork" }] } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "submitted" }] }, "amount" : { "value" : 150, "currency" : "USD" } }] }], "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "renderingnetworkstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "innetwork" }] } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "benefitpaymentstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "innetwork" }] } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator", "code" : "billingnetworkstatus" }] }, "reason" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus", "code" : "innetwork" }] } }], "total" : [{ "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "submitted" }], "text" : "Submitted Amount" }, "amount" : { "value" : 150, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "version" : "1.0.1", "code" : "benefit" }], "text" : "Benefit Amount" }, "amount" : { "value" : 110, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "discount" }], "text" : "Discount Amount" }, "amount" : { "value" : 40, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication", "code" : "paidtoprovider" }], "text" : "Amount Paid to Provider" }, "amount" : { "value" : 100, "currency" : "USD" } }] }