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

: EOBOral2 - JSON Representation

Raw json | Download


{
  "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|1.2.0"
    ]
  },
  "language" : "en-US",
  "text" : {
    "status" : "generated",
    "div" : "<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 \"EOBOral2\" Updated \"2021-10-28T15:23:00Z\"  (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: 210300012</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>: 2021-10-01 --&gt; 2021-10-31</p><p><b>created</b>: 2021-10-28T10:23:00-05:00</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>: 8</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>: 9</p><p><b>category</b>: Additional Body Site <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#additionalbodysite)</span></p><p><b>code</b>: 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAUniversalNumberingSystem.html\">American Dental Association Universal Numbering System</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: Additional Body Site <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#additionalbodysite)</span></p><p><b>code</b>: 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAUniversalNumberingSystem.html\">American Dental Association Universal Numbering System</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</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>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>informationSequence</b>: 6, 7, 9, 10, 11</p><p><b>productOrService</b>: Intraoral - periapical first radiographic image <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADADentalProcedureCode.html\">ADA Code on Dental Procedures and Nomenclature</a>#D0220)</span></p><p><b>serviced</b>: 2021-10-28</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><p><b>bodySite</b>: Upper right quadrant <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ADAAreaOfOralCavitySystem.html\">American Dental Association Area of Oral Cavity System</a>#10)</span></p><p><b>subSite</b>: Occlusal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSurfaceCodes.html\">US Surface Codes System</a>#O)</span>, Incisal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSurfaceCodes.html\">US Surface Codes System</a>#I)</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>"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code" : "uc"
          }
        ]
      },
      "system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
      "value" : "210300012"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ],
    "text" : "Oral"
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/Patient1"
  },
  "billablePeriod" : {
    "start" : "2021-10-01",
    "end" : "2021-10-31"
  },
  "created" : "2021-10-28T10:23:00-05:00",
  "insurer" : {
    "reference" : "Organization/OrganizationDentalPayer1",
    "display" : "XXX Health Plan"
  },
  "provider" : {
    "reference" : "Practitioner/PractitionerDentalProvider1",
    "display" : "XXX Dental Plan"
  },
  "outcome" : "complete",
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "billingnetworkcontractingstatus"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "contracted"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "performingnetworkcontractingstatus"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "contracted"
          }
        ]
      }
    },
    {
      "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/OrganizationProvider1"
      }
    },
    {
      "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" : "https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
            "code" : "1"
          }
        ]
      }
    },
    {
      "sequence" : 10,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "additionalbodysite"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
            "code" : "2"
          }
        ]
      }
    },
    {
      "sequence" : 11,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/CoverageDental1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "informationSequence" : [
        6,
        7,
        9,
        10,
        11
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "https://www.ada.org/en/publications/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" : "https://ada.org/OralCavityCode-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
            "code" : "10",
            "display" : "Upper right quadrant"
          }
        ]
      },
      "subSite" : [
        {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes",
              "code" : "O"
            }
          ]
        },
        {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSurfaceCodes",
              "code" : "I"
            }
          ]
        }
      ],
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          },
          "amount" : {
            "value" : 150,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
                "code" : "innetwork"
              }
            ]
          }
        }
      ]
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted"
          }
        ],
        "text" : "Submitted Amount"
      },
      "amount" : {
        "value" : 150,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "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"
      }
    }
  ]
}