CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.2.0 - STU 2.2 United States of America flag

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 2.2.0 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

: BB-EOBOral2-nonfinancial

Page standards status: Informative

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "BB-EOBOral2-nonfinancial",
  "meta" : {
    "lastUpdated" : "2021-10-28T10:23:00-05:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis|2.2.0"
    ]
  },
  "language" : "en",
  "text" : {
    "status" : "generated"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code" : "uc"
          }
        ]
      },
      "system" : "https://www.example.com/fhir/EOBIdentifier",
      "value" : "210300012"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "version" : "1.0.1",
        "code" : "oral"
      }
    ],
    "text" : "Oral"
  },
  "use" : "claim",
  "patient" : {
    🔗 "reference" : "Patient/Patient2"
  },
  "billablePeriod" : {
    "start" : "2021-10-01",
    "end" : "2021-10-31"
  },
  "created" : "2021-10-28T10:23:00-05:00",
  "insurer" : {
    🔗 "reference" : "Organization/DentalPayer1",
    "display" : "XXX Health Plan"
  },
  "provider" : {
    🔗 "reference" : "Practitioner/PractitionerDentalProvider1",
    "display" : "XXX Dental Plan"
  },
  "outcome" : "complete",
  "supportingInfo" : [
    {
      "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/ProviderOrganization1"
      }
    },
    {
      "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" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem",
            "code" : "1"
          }
        ]
      }
    },
    {
      "sequence" : 10,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "additionalbodysite"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem",
            "code" : "2"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/CoverageDental1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "informationSequence" : [
        6,
        7,
        9,
        10,
        11
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ada.org/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" : "http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem",
            "code" : "10",
            "display" : "Upper right quadrant"
          }
        ]
      },
      "subSite" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes",
              "code" : "O"
            }
          ]
        },
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes",
              "code" : "I"
            }
          ]
        }
      ],
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
                "code" : "benefitpaymentstatus"
              }
            ]
          },
          "reason" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
                "code" : "innetwork"
              }
            ]
          }
        }
      ]
    }
  ],
  "adjudication" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "renderingnetworkstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "benefitpaymentstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "billingnetworkstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    }
  ]
}