CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.2.0 - STU 2 Ballot

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 "2021-03-18T15:23:00Z" (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: 2021-03-18T10:23:00-05:00

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)