CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot
This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions 
Generated Narrative
Resource "EOBPharmacy1" Updated "2019-12-12T09:14:11Z" (Language "en-US")
identifier: Unique Claim ID: AW123412341234123412341234123412
status: active
type: Pharmacy (Claim Type Codes#pharmacy)
use: claim
patient: Patient/Patient1 " EXAMPLE1"
billablePeriod: 2019-10-30 --> 2019-10-31
created: 2019-07-02T00:00:00Z
insurer: Organization/Payer1: XXX Health Plan "Payer 1"
provider: Organization/OrganizationProvider1: XXX Health Plan "Provider 1"
outcome: partial
supportingInfo
sequence: 8
category: Days Supply (C4BB Supporting Info Type#dayssupply)
value: 30
supportingInfo
sequence: 6
category: DAW (Dispense As Written) Code (C4BB Supporting Info Type#dawcode)
code: 7 (NCPDP Dispense As Written (DAW)/Product Selection Code#7)
supportingInfo
sequence: 4
category: Refill Number (C4BB Supporting Info Type#refillnum)
value: 0
supportingInfo
sequence: 5
category: Refills Authorized (C4BB Supporting Info Type#refillsauthorized)
value: 0
supportingInfo
sequence: 1
category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)
code: Contracted (C4BB Payer Adjudication Status#contracted)
supportingInfo
sequence: 2
category: Brand Generic Indicator (C4BB Supporting Info Type#brandgenericindicator)
code: 2 (NCPDP Brand Generic Indicator#2)
supportingInfo
sequence: 3
category: Rx Origin Code (C4BB Supporting Info Type#rxorigincode)
code: 1 (NCPDP Prescription Origin Code#1)
supportingInfo
sequence: 7
category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)
timing: 2019-10-31
supportingInfo
sequence: 9
category: Compound Code (C4BB Supporting Info Type#compoundcode)
code: Dummy (NCPDP Compound Code#Dummy)
supportingInfo
sequence: 10
category: In Network (C4BB Payer Adjudication Status#innetwork)
| - | Focal | Coverage |
| * | true | Coverage/Coverage1 |
item
sequence: 1
productOrService: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) (National drug codes#0777-3105-02)
serviced: 2019-07-02
adjudication
category: Submitted Amount (Adjudication Value Codes#submitted)
adjudication
category: Benefit Amount (Adjudication Value Codes#benefit)
adjudication
category: Discount (C4BB Adjudication#discount)
adjudication
category: Member liability (C4BB Adjudication#memberliability)
adjudication
category: Paid to provider (C4BB Adjudication#paidtoprovider)
total
category: Payment Amount (C4BB Adjudication#paidtoprovider)
total
category: Submitted Amount (Adjudication Value Codes#submitted)
total
category: Patient Pay Amount (C4BB Adjudication#paidbypatient)
| Field | Value |
| resourceType | "ExplanationOfBenefit" |
| id | "EOBPharmacy1" |
| meta.profile[0] | "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy" |
| meta.lastUpdated | "2019-12-12T09:14:11+00:00" |
| type.coding[0].code | #pharmacy |
| type.coding[0].system | "http://terminology.hl7.org/CodeSystem/claim-type" |
| type.text | "Pharmacy" |
| use | "claim" |
| supportingInfo[0].category.coding[0].code | #dayssupply |
| supportingInfo[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[0].sequence | 7 |
| supportingInfo[0].valueQuantity.value | 30 |
| supportingInfo[1].category.coding[0].code | #dawcode |
| supportingInfo[1].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[1].code.coding[0].code | #7 |
| supportingInfo[1].code.coding[0].system | "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode" |
| supportingInfo[1].sequence | 5 |
| supportingInfo[2].category.coding[0].code | #refillnum |
| supportingInfo[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[2].valueQuantity.value | 0 |
| supportingInfo[2].sequence | 4 |
| supportingInfo[3].category.coding[0].code | #billingnetworkcontractingstatus |
| supportingInfo[3].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[3].sequence | 1 |
| supportingInfo[3].code.coding[0].code | #contracted |
| supportingInfo[3].code.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| supportingInfo[4].category.coding[0].code | #brandgenericindicator |
| supportingInfo[4].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[4].sequence | 2 |
| supportingInfo[4].code.coding[0].code | #2 |
| supportingInfo[4].code.coding[0].system | "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator" |
| supportingInfo[5].category.coding[0].code | #rxorigincode |
| supportingInfo[5].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[5].code.coding[0].code | #1 |
| supportingInfo[5].code.coding[0].system | "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode" |
| supportingInfo[5].sequence | 3 |
| supportingInfo[6].category.coding[0].code | #clmrecvddate |
| supportingInfo[6].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[6].timingDate | "2019-10-31" |
| supportingInfo[6].sequence | 6 |
| supportingInfo[7].category.coding[0].code | #compoundcode |
| supportingInfo[7].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" |
| supportingInfo[7].code.coding[0].code | #Dummy |
| supportingInfo[7].code.coding[0].system | "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode" |
| supportingInfo[7].sequence | 8 |
| language | "en-US" |
| status | "active" |
| identifier[0].type.coding[0].code | #uc |
| identifier[0].type.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" |
| identifier[0].value | AW123412341234123412341234123412 |
| identifier[0].system | "https://www.xxxplan.com/fhir/EOBIdentifier" |
| created | "2019-07-02T00:00:00+00:00" |
| insurer.reference | "Organization/Payer1" |
| insurer.display | "XXX Health Plan" |
| patient.reference | "Patient/Patient1" |
| billablePeriod.start | "2019-10-30" |
| billablePeriod.end | "2019-10-31" |
| provider.reference | "Organization/OrganizationProvider1" |
| provider.display | "XXX Health Plan" |
| outcome | "partial" |
| insurance[0].focal | "true" |
| insurance[0].coverage.reference | "Coverage/Coverage1" |
| total[0].category.coding[0].code | #paidtoprovider |
| total[0].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[0].category.text | "Payment Amount" |
| total[0].amount.value | 620 |
| total[0].amount.currency | #USD |
| total[1].category.coding[0].code | #submitted |
| total[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| total[1].category.text | "Submitted Amount" |
| total[1].amount.value | 2650 |
| total[1].amount.currency | #USD |
| total[2].category.coding[0].code | #paidbypatient |
| total[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| total[2].category.text | "Patient Pay Amount" |
| total[2].amount.value | 0 |
| total[2].amount.currency | #USD |
| total[3].category.coding[0].code | #innetwork |
| total[3].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" |
| total[3].amount.value | 0 |
| total[3].amount.currency | #USD |
| item[0].productOrService.coding[0].code | #0777-3105-02 |
| item[0].productOrService.coding[0].system | "http://hl7.org/fhir/sid/ndc" |
| item[0].productOrService.coding[0].display | "100 CAPSULE in 1 BOTTLE (0777-3105-02)" |
| item[0].sequence | 1 |
| item[0].adjudication[0].category.coding[0].code | #submitted |
| item[0].adjudication[0].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[0].amount.value | 1000 |
| item[0].adjudication[0].amount.currency | #USD |
| item[0].adjudication[1].category.coding[0].code | #benefit |
| item[0].adjudication[1].category.coding[0].system | "http://terminology.hl7.org/CodeSystem/adjudication" |
| item[0].adjudication[1].amount.value | 20 |
| item[0].adjudication[1].amount.currency | #USD |
| item[0].adjudication[2].category.coding[0].code | #discount |
| item[0].adjudication[2].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[0].adjudication[2].amount.value | 900 |
| item[0].adjudication[2].amount.currency | #USD |
| item[0].adjudication[3].category.coding[0].code | #memberliability |
| item[0].adjudication[3].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[0].adjudication[3].amount.value | 80 |
| item[0].adjudication[3].amount.currency | #USD |
| item[0].adjudication[4].category.coding[0].code | #paidtoprovider |
| item[0].adjudication[4].category.coding[0].system | "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" |
| item[0].adjudication[4].amount.value | 20 |
| item[0].adjudication[4].amount.currency | #USD |
IG © 2021+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.2.0 based on FHIR 4.0.1. Generated 2021-12-06
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