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

: EOB Oral Example 2

Page standards status: Informative

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBOral2"/>
  <meta>
    <lastUpdated value="2021-10-28T10:23:00-05:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.2.0"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.example.com/fhir/EOBIdentifier"/>
    <value value="210300012"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <version value="1.0.1"/>
      <code value="oral"/>
    </coding>
    <text value="Oral"/>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient2"/>
  </patient>
  <billablePeriod>
    <start value="2021-10-01"/>
    <end value="2021-10-31"/>
  </billablePeriod>
  <created value="2021-10-28T10:23:00-05:00"/>
  <insurer>🔗 
    <reference value="Organization/DentalPayer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Practitioner/PractitionerDentalProvider1"/>
    <display value="XXX Dental Plan"/>
  </provider>
  <outcome value="complete"/>
  <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/ProviderOrganization1"/>
    </valueReference>
  </supportingInfo>
  <supportingInfo>
    <sequence value="8"/>
    <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="9"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="additionalbodysite"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
        <code value="1"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="10"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="additionalbodysite"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem"/>
        <code value="2"/>
      </coding>
    </code>
  </supportingInfo>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/CoverageDental1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <informationSequence value="6"/>
    <informationSequence value="7"/>
    <informationSequence value="9"/>
    <informationSequence value="10"/>
    <informationSequence value="11"/>
    <productOrService>
      <coding>
        <system value="http://www.ada.org/cdt"/>
        <code value="D0220"/>
        <display value="Intraoral - periapical first radiographic image"/>
      </coding>
    </productOrService>
    <servicedDate value="2021-10-28"/>
    <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>
    <bodySite>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem"/>
        <code value="10"/>
        <display value="Upper right quadrant"/>
      </coding>
    </bodySite>
    <subSite>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"/>
        <code value="O"/>
      </coding>
    </subSite>
    <subSite>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes"/>
        <code value="I"/>
      </coding>
    </subSite>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
          <code value="benefitpaymentstatus"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
          <code value="innetwork"/>
        </coding>
      </reason>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <version value="1.0.1"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="150"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="renderingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <version value="1.0.1"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="150"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <version value="1.0.1"/>
        <code value="benefit"/>
      </coding>
      <text value="Benefit Amount"/>
    </category>
    <amount>
      <value value="110"/>
      <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="40"/>
      <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="100"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>