FHIRsmith: ExplanationOfBenefit/ExplanationOfBenefit-EOBOral2.json

FHIR IG analytics

Package	hl7.fhir.us.carin-bb
Resource Type	ExplanationOfBenefit
Id	ExplanationOfBenefit-EOBOral2.json
FHIR Version	R4

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: ExplanationOfBenefit EOBOral2

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

Profile: C4BB ExplanationOfBenefit Oralversion: null2.2.0)

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

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
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
- Value Currency
* 150 United States dollar

Adjudications

Category

Reason

Rendering Network Status

In Network

Benefit Payment Status

In Network

Billing Network Status

In Network

total
category: Submitted Amount
Amounts
- Value Currency
* 150 United States dollar

total
category: Benefit Amount
Amounts
- Value Currency
* 110 United States dollar

total
category: Discount Amount
Amounts
- Value Currency
* 40 United States dollar

total
category: Amount Paid to Provider
Amounts
- Value Currency
* 100 United States dollar

Source1

{
  "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|2.2.0"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "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"
              }
            ]
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "version": "1.0.1",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 150,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "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"
          }
        ]
      }
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "version": "1.0.1",
            "code": "submitted"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 150,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "version": "1.0.1",
            "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"
      }
    }
  ]
}