BB-EOBOral1-nonfinancial - CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) v2.1.0

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: BB-EOBOral1-nonfinancial

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit BB-EOBOral1-nonfinancial

Last updated: 2021-03-18 10:23:00-0500; Language: en-US

Profile: C4BB ExplanationOfBenefit Oral Basisversion: null2.1.0)

identifier: Unique Claim ID/210300002

status: Active

type: Oral

use: Claim

patient: Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)

billablePeriod: 2021-03-01 --> 2021-03-31

created: 2021-03-18 10:23:00-0500

insurer: XXX Health Plan

provider: XXX Dental Plan

outcome: Processing Complete

supportingInfo
sequence: 3
category: Claim Received Date
timing: 2021-03-18

supportingInfo
sequence: 4
category: Service Facility
value: Organization Orange Medical Group

supportingInfo
sequence: 5
category: Patient Account Number
value: PATIENTACCTNO3

Diagnoses

Sequence

Diagnosis[x]

Type

1

Encounter for dental examination and cleaning with abnormal findings

Principal Diagnosis

Insurances

Focal

Coverage

true

Coverage: identifier = Member Number; status = active; type = dental care policy; subscriberId = 10300007; dependent = 01; relationship = Self; period = 2021-01-01 --> 2021-12-31; network = INSURANCE COMPANY XYZ - PRIME

item
sequence: 1
productOrService: Prophylaxis - Adult
serviced: 2021-03-18
location: Office
Adjudications
- Category Reason
* Benefit Payment Status In Network

item
sequence: 2
productOrService: Periodic oral evaluation
serviced: 2021-03-18
location: Office
Adjudications
- Category Reason
* Benefit Payment Status In Network

Adjudications

Category

Reason

Rendering Network Status

In Network

Benefit Payment Status

In Network

Billing Network Status

In Network

IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2025-02-18
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