CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Pre-Publish
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Pre-Publish
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), 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
Generated Narrative
Resource "EOBOral1a" Updated "2021-03-18 10:23:00-0500" (Language "en-US")
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)
| - | Sequence | Diagnosis[x] | Type |
| * | 1 | Encounter 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) |
| - | Focal | Coverage |
| * | true | Coverage/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)
| Field | Value |
| 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 |
IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.2.0 based on FHIR 4.0.1. Generated 2022-07-27
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