C4BBExplanationOfBenefitOralBasis

C4BB ExplanationOfBenefit Oral Basis

activeCARIN Blue Button2.2.0resource51 key elements

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. The basis profile does not have requirements for financial data.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis
ID
C4BB-ExplanationOfBenefit-Oral-Basis
Type
Base Definition
C4BB-ExplanationOfBenefit
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
careTeam.role
1+
careTeam.qualification
S
:clmrecvddate0..1
S
Claim received date
supportingInfo.category
S
supportingInfo.timing[x]
date
S1+
:servicefacility0..1
S
Service facility
supportingInfo.category
S
supportingInfo.value[x]
1+
:valueReference1..1
Reference
S1+
:orthodontics0..1
S
Orthodontics treatment indicator
supportingInfo.category
S
supportingInfo.value[x]
Quantity
S1+
Total number of months for orthodontia
:prosthesis0..1
S
Prosthesis
supportingInfo.category
S
supportingInfo.value[x]
boolean
S1+
Prosthesis replacement indicator (202
:additionalbodysite0..*
S
Additional tooth number or oral cavity code
supportingInfo.sequence
S
supportingInfo.category
S
supportingInfo.code
S1+
:missingtoothnumber0..*
S
Missing tooth number
supportingInfo.category
S
supportingInfo.code
S1+
:medicalrecordnumber0..1
S
Medical record number
supportingInfo.value[x]
1+
:valueString1..1
string
S1+
:patientaccountnumber0..1
S
Patient account number
supportingInfo.value[x]
1+
:valueString1..1
string
S1+
diagnosis
S
diagnosis.diagnosis[x]
CodeableConcept
S
diagnosis.type1..1
S1+
item.informationSequence
S
item.productOrService
S
item.modifier
S
item.serviced[x]
S1+
item.location[x]
CodeableConcept
S1+
item.bodySite
S
First tooth number or oral cavity code
item.adjudication
S1+
:adjustmentreason0..*
S
Reason codes used to interpret the Non-Covered Amount (92)
item.adjudication.reason
S1+
:benefitpaymentstatus1..1
S1+
Indicates the in network or out of network payment status of the claim. (142)
item.adjudication.reason
S1+
:allowedunits0..1
S
The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
adjudication
BackboneElement
S1+
adjudication.category
S
:billingnetworkstatus0..1
S
Billing provider network status
adjudication.reason
S1+
:renderingnetworkstatus1..1
S1+
Rendering provider network status
adjudication.reason
S1+
:benefitpaymentstatus1..*
S1+
Indicates the in network or out of network payment status of the claim. (142)
adjudication.reason
S1+