CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1
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
| Page standards status: Informative |
Generated Narrative: ExplanationOfBenefit EOBOral1
Last updated: 2021-03-18 10:23:00-0500; Language: en-US
identifier: Unique Claim ID/210300002
status: Active
type: Oral
use: Claim
billablePeriod: 2021-03-01 --> 2021-03-31
created: 2021-03-18 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
supportingInfo
sequence: 5
category: Patient Account Number
value: PATIENTACCTNO3
| Sequence | Diagnosis[x] | Type |
| 1 | Encounter for dental examination and cleaning with abnormal findings | Principal Diagnosis |
item
sequence: 1
productOrService: Prophylaxis - Adult
serviced: 2021-03-18
location: Office
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: Submitted Amount
Amounts
Value Currency 190 United States dollar
item
sequence: 2
productOrService: Periodic oral evaluation
serviced: 2021-03-18
location: Office
adjudication
category: Benefit Payment Status
reason: In Network
adjudication
category: Submitted Amount
Amounts
Value Currency 220 United States dollar
| Category | Reason |
| Rendering Network Status | In Network |
| Benefit Payment Status | In Network |
| Billing Network Status | In Network |
total
category: Submitted Amount
Amounts
Value Currency 410 United States dollar
total
category: Benefit Amount
Amounts
Value Currency 350 United States dollar
total
category: Discount Amount
Amounts
Value Currency 60 United States dollar
total
category: Amount Paid to Provider
Amounts
Value Currency 350 United States dollar
Instance: EOBOral1
InstanceOf: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.1.0
Title: "EOB Oral Example 1"
Description: "EOB Oral Example 1"
Usage: #example
* meta.lastUpdated = "2021-03-18T10:23:00-05:00"
* language = #en-US
* identifier
* type = C4BBIdentifierType#uc
* system = "https://www.xxxplan.com/fhir/EOBIdentifier"
* value = "210300002"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#oral
* text = "Oral"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod
* start = "2021-03-01"
* end = "2021-03-31"
* created = "2021-03-18T10:23:00-05:00"
* insurer = Reference(DentalPayer1) "XXX Health Plan"
* provider = Reference(PractitionerDentalProvider1) "XXX Dental Plan"
* outcome = #complete
* supportingInfo[0]
* sequence = 3
* category = C4BBSupportingInfoType#clmrecvddate
* timingDate = "2021-03-18"
* supportingInfo[+]
* sequence = 4
* category = C4BBSupportingInfoType#servicefacility
* valueReference = Reference(ProviderOrganization1)
* supportingInfo[+]
* sequence = 5
* category = C4BBSupportingInfoType#patientaccountnumber
* valueString = "PATIENTACCTNO3"
* diagnosis
* sequence = 1
* diagnosisCodeableConcept = http://hl7.org/fhir/sid/icd-10-cm#Z01.21 "Encounter for dental examination and cleaning with abnormal findings"
* type = http://terminology.hl7.org/CodeSystem/ex-diagnosistype#principal
* insurance
* focal = true
* coverage = Reference(CoverageDental1)
* item[0]
* sequence = 1
* productOrService = http://www.ada.org/cdt#D1110 "Prophylaxis - Adult"
* servicedDate = "2021-03-18"
* locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* adjudication[0]
* category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
* reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
* category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* amount
* value = 190
* currency = #USD
* item[+]
* sequence = 2
* productOrService = http://www.ada.org/cdt#D0120 "Periodic oral evaluation"
* servicedDate = "2021-03-18"
* locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
* adjudication[0]
* category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
* reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
* category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* amount
* value = 220
* currency = #USD
* adjudication[0]
* category = C4BBAdjudicationDiscriminator#renderingnetworkstatus
* reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
* category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
* reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
* category = C4BBAdjudicationDiscriminator#billingnetworkstatus
* reason = C4BBPayerAdjudicationStatus#innetwork
* total[0]
* category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* text = "Submitted Amount"
* amount
* value = 410
* currency = #USD
* total[+]
* category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
* text = "Benefit Amount"
* amount
* value = 350
* currency = #USD
* total[+]
* category = C4BBAdjudication#discount
* text = "Discount Amount"
* amount
* value = 60
* currency = #USD
* total[+]
* category = C4BBAdjudication#paidtoprovider
* text = "Amount Paid to Provider"
* amount
* value = 350
* currency = #USD
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2024-11-21
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