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

: EOBOral1a - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBOral1a"/>
  <meta>
    <lastUpdated value="2021-03-18T10:23:00-05:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative</b></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource "EOBOral1a" Updated "2021-03-18T15:23:00Z"  (Language "en-US") </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Oral.html">C4BB ExplanationOfBenefit Oral (version 1.2.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: 210300002</p><p><b>status</b>: active</p><p><b>type</b>: Oral <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-claim-type.html">Claim Type Codes</a>#oral)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-Patient1.html">Patient/Patient1</a> " EXAMPLE1"</p><p><b>billablePeriod</b>: 2021-03-01 --&gt; 2021-03-31</p><p><b>created</b>: 2021-03-18T10:23:00-05:00</p><p><b>insurer</b>: <a href="Organization-OrganizationDentalPayer1.html">Organization/OrganizationDentalPayer1: XXX Health Plan</a> "INSURANCE COMPANY XYZ"</p><p><b>provider</b>: <a href="Practitioner-PractitionerDentalProvider1.html">Practitioner/PractitionerDentalProvider1: XXX Dental Plan</a> " SCHMIDT"</p><p><b>outcome</b>: complete</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Billing Network Contracting Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#billingnetworkcontractingstatus)</span></p><p><b>code</b>: Contracted <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#contracted)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Performing Network Contracting Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#performingnetworkcontractingstatus)</span></p><p><b>code</b>: Contracted <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#contracted)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Claim Received Date <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#clmrecvddate)</span></p><p><b>timing</b>: 2021-03-18</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Service Facility <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#servicefacility)</span></p><p><b>value</b>: <a href="Organization-OrganizationProvider1.html">Organization/OrganizationProvider1</a> "Provider 1"</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Patient Account Number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type</a>#patientaccountnumber)</span></p><p><b>value</b>: PATIENTACCTNO3</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1</td><td>Encounter for dental examination and cleaning with abnormal findings <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#Z01.21)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-CoverageDental1.html">Coverage/CoverageDental1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Prophylaxis - Adult <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-ADADentalProcedureCode.html">ADA Code on Dental Procedures and Nomenclature</a>#D1110)</span></p><p><b>serviced</b>: 2021-03-18</p><p><b>location</b>: Office <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#11)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: Periodic oral evaluation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-ADADentalProcedureCode.html">ADA Code on Dental Procedures and Nomenclature</a>#D0120)</span></p><p><b>serviced</b>: 2021-03-18</p><p><b>location</b>: Office <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#11)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status</a>#innetwork)</span></p></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Benefit Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#benefit)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Discount Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#discount)</span></p></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount Paid to Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication</a>#paidtoprovider)</span></p></blockquote></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
    <value value="210300002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
    <text value="Oral"/>
  </type>
  <use value="claim"/>
  <patient>
    <reference value="Patient/Patient1"/>
  </patient>
  <billablePeriod>
    <start value="2021-03-01"/>
    <end value="2021-03-31"/>
  </billablePeriod>
  <created value="2021-03-18T10:23:00-05:00"/>
  <insurer>
    <reference value="Organization/OrganizationDentalPayer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>
    <reference value="Practitioner/PractitionerDentalProvider1"/>
    <display value="XXX Dental Plan"/>
  </provider>
  <outcome value="complete"/>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="billingnetworkcontractingstatus"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="contracted"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="performingnetworkcontractingstatus"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="contracted"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2021-03-18"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="4"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="servicefacility"/>
      </coding>
    </category>
    <valueReference>
      <reference value="Organization/OrganizationProvider1"/>
    </valueReference>
  </supportingInfo>
  <supportingInfo>
    <sequence value="5"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="patientaccountnumber"/>
      </coding>
    </category>
    <valueString value="PATIENTACCTNO3"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="6"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </category>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="Z01.21"/>
        <display
                 value="Encounter for dental examination and cleaning with abnormal findings"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/CoverageDental1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="https://www.ada.org/en/publications/cdt"/>
        <code value="D1110"/>
        <display value="Prophylaxis - Adult"/>
      </coding>
    </productOrService>
    <servicedDate value="2021-03-18"/>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="11"/>
        <display value="Office"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="190"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
          <code value="innetwork"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <sequence value="2"/>
    <productOrService>
      <coding>
        <system value="https://www.ada.org/en/publications/cdt"/>
        <code value="D0120"/>
        <display value="Periodic oral evaluation"/>
      </coding>
    </productOrService>
    <servicedDate value="2021-03-18"/>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="11"/>
        <display value="Office"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="220"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
          <code value="innetwork"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="410"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
      </coding>
      <text value="Benefit Amount"/>
    </category>
    <amount>
      <value value="350"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="discount"/>
      </coding>
      <text value="Discount Amount"/>
    </category>
    <amount>
      <value value="60"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Amount Paid to Provider"/>
    </category>
    <amount>
      <value value="350"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>