CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0-snapshot1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

: EOB Pharmacy Example1 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBPharmacy1"/>
  <meta>
    <lastUpdated value="2019-12-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.1.0-snapshot1"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit EOBPharmacy1</b></p><a name="EOBPharmacy1"> </a><a name="hcEOBPharmacy1"> </a><a name="EOBPharmacy1-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2019-12-12 09:14:11+0000; Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Pharmacy.html">C4BB ExplanationOfBenefit Pharmacyversion: {0}2.1.0-snapshot1)</a></p></div><p><b>identifier</b>: Unique Claim ID/AW123412341234123412341234123412</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type pharmacy}">Pharmacy</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">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)</a></p><p><b>billablePeriod</b>: 2019-10-30 --&gt; 2019-10-31</p><p><b>created</b>: 2019-07-02 00:00:00+0000</p><p><b>insurer</b>: <a href="Organization-Payer1.html">XXX Health Plan</a></p><p><b>provider</b>: <a href="Organization-ProviderOrganization1.html">XXX Health Plan</a></p><p><b>outcome</b>: Partial Processing</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dayssupply}">Days Supply</span></p><p><b>value</b>: 30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dawcode}">DAW (Dispense As Written) Code</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode 7}">7</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType refillnum}">Refill Number</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType refillsauthorized}">Refills Authorized</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType brandgenericindicator}">Brand Generic Indicator</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator 2}">2</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType rxorigincode}">Rx Origin Code</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode 1}">1</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Claim Received Date</span></p><p><b>timing</b>: 2019-10-31</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType compoundcode}">Compound Code</span></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode Dummy}">Dummy</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Coverage-Coverage3.html">Coverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --&gt; 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://hl7.org/fhir/sid/ndc 0777-3105-02}">Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)</span></p><p><b>serviced</b>: 2019-07-02</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>1000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}">Benefit Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication discount}">Discount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>900</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication memberliability}">Member liability</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>80</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}">Paid to provider</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>20</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}">Benefit Payment Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}">Billing Network Status</span></td><td><span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}">In Network</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}">Payment Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>620</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>2650</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidbypatient}">Patient Pay Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.xxxplan.com/fhir/EOBIdentifier"/>
    <value value="AW123412341234123412341234123412"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="pharmacy"/>
    </coding>
    <text value="Pharmacy"/>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient2"/>
  </patient>
  <billablePeriod>
    <start value="2019-10-30"/>
    <end value="2019-10-31"/>
  </billablePeriod>
  <created value="2019-07-02T00:00:00+00:00"/>
  <insurer>🔗 
    <reference value="Organization/Payer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ProviderOrganization1"/>
    <display value="XXX Health Plan"/>
  </provider>
  <outcome value="partial"/>
  <supportingInfo>
    <sequence value="8"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="dayssupply"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="30"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="6"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="dawcode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode"/>
        <code value="7"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="4"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="refillnum"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="0"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="5"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="refillsauthorized"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="0"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="brandgenericindicator"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator"/>
        <code value="2"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="rxorigincode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode"/>
        <code value="1"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="7"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2019-10-31"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="9"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="compoundcode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/Coverage3"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/sid/ndc"/>
        <code value="0777-3105-02"/>
        <display
                 value="Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"/>
      </coding>
    </productOrService>
    <servicedDate value="2019-07-02"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="1000"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="20"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="discount"/>
        </coding>
      </category>
      <amount>
        <value value="900"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="memberliability"/>
        </coding>
      </category>
      <amount>
        <value value="80"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="paidtoprovider"/>
        </coding>
      </category>
      <amount>
        <value value="20"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <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://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Payment Amount"/>
    </category>
    <amount>
      <value value="620"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="2650"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidbypatient"/>
      </coding>
      <text value="Patient Pay Amount"/>
    </category>
    <amount>
      <value value="0"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>