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: EOB Oral Example 2

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit EOBOral2

Last updated: 2021-10-28 10:23:00-0500; Language: en-US

Profile: C4BB ExplanationOfBenefit Oralversion: null2.1.0)

identifier: Unique Claim ID/210300012

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: 2021-10-01 --> 2021-10-31

created: 2021-10-28 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: 8

category: Patient Account Number

value: PATIENTACCTNO3

supportingInfo

sequence: 9

category: Additional Body Site

code: Permanent maxillary right third molar tooth

supportingInfo

sequence: 10

category: Additional Body Site

code: Permanent maxillary right second molar tooth

Insurances

-FocalCoverage
*trueCoverage: 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

informationSequence: 6, 7, 9, 10, 11

productOrService: Intraoral - periapical first radiographic image

serviced: 2021-10-28

location: Office

bodySite: Upper right quadrant

subSite: Occlusal, Incisal

adjudication

category: Benefit Payment Status

reason: In Network

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*150United States dollar

Adjudications

-CategoryReason
*Rendering Network StatusIn Network
*Benefit Payment StatusIn Network
*Billing Network StatusIn Network

total

category: Submitted Amount

Amounts

-ValueCurrency
*150United States dollar

total

category: Benefit Amount

Amounts

-ValueCurrency
*110United States dollar

total

category: Discount Amount

Amounts

-ValueCurrency
*40United States dollar

total

category: Amount Paid to Provider

Amounts

-ValueCurrency
*100United States dollar

Notes:

Instance: EOBOral2
InstanceOf: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.1.0
Title: "EOB Oral Example 2"
Description: "EOB Oral Example 2"
Usage: #example
* meta.lastUpdated = "2021-10-28T10:23:00-05:00"
* language = #en-US
* identifier
  * type = C4BBIdentifierType#uc
  * system = "https://www.xxxplan.com/fhir/EOBIdentifier"
  * value = "210300012"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#oral
  * text = "Oral"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod
  * start = "2021-10-01"
  * end = "2021-10-31"
* created = "2021-10-28T10:23:00-05:00"
* insurer = Reference(DentalPayer1) "XXX Health Plan"
* provider = Reference(PractitionerDentalProvider1) "XXX Dental Plan"
* outcome = #complete
* supportingInfo[0]
  * sequence = 3
  * category = C4BBSupportingInfoType#clmrecvddate
  * timingDate = "2021-03-18"
* supportingInfo[+]
  * sequence = 4
  * category = C4BBSupportingInfoType#servicefacility
  * valueReference = Reference(ProviderOrganization1)
* supportingInfo[+]
  * sequence = 8
  * category = C4BBSupportingInfoType#patientaccountnumber
  * valueString = "PATIENTACCTNO3"
* supportingInfo[+]
  * sequence = 9
  * category = C4BBSupportingInfoType#additionalbodysite
  * code = http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem#1
* supportingInfo[+]
  * sequence = 10
  * category = C4BBSupportingInfoType#additionalbodysite
  * code = http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem#2
* insurance
  * focal = true
  * coverage = Reference(CoverageDental1)
* item
  * sequence = 1
  * informationSequence[0] = 6
  * informationSequence[+] = 7
  * informationSequence[+] = 9
  * informationSequence[+] = 10
  * informationSequence[+] = 11
  * productOrService = http://www.ada.org/cdt#D0220 "Intraoral - periapical first radiographic image"
  * servicedDate = "2021-10-28"
  * locationCodeableConcept = https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set#11 "Office"
  * bodySite = http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem#10 "Upper right quadrant"
  * subSite[0] = C4BBSurfaceCodes#O
  * subSite[+] = C4BBSurfaceCodes#I
  * adjudication[0]
    * category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
    * reason = C4BBPayerAdjudicationStatus#innetwork
  * adjudication[+]
    * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
    * amount
      * value = 150
      * currency = #USD
* adjudication[0]
  * category = C4BBAdjudicationDiscriminator#renderingnetworkstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
  * category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
  * category = C4BBAdjudicationDiscriminator#billingnetworkstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* total[0]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
    * text = "Submitted Amount"
  * amount
    * value = 150
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
    * text = "Benefit Amount"
  * amount
    * value = 110
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#discount
    * text = "Discount Amount"
  * amount
    * value = 40
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#paidtoprovider
    * text = "Amount Paid to Provider"
  * amount
    * value = 100
    * currency = #USD