HL7.FHIR.US.CARIN-BB\EOB Pharmacy Example1

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 US

This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Pharmacy Example1

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "EOBPharmacy1" Updated "2019-12-12 09:14:11+0000" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Pharmacy (version 2.0.0)

identifier: Unique Claim ID: AW123412341234123412341234123412

status: active

type: Pharmacy (Claim Type Codes#pharmacy)

use: claim

patient: Patient/Patient2 " TEST"

billablePeriod: 2019-10-30 --> 2019-10-31

created: 2019-07-02 12:00:00+0000

insurer: Organization/Payer1: XXX Health Plan "Organization Payer 1"

provider: Organization/ProviderOrganization1: XXX Health Plan "Orange Medical Group"

outcome: partial

supportingInfo
sequence: 8
category: Days Supply (C4BB Supporting Info Type Code System#dayssupply)
value: 30

supportingInfo
sequence: 6
category: DAW (Dispense As Written) Code (C4BB Supporting Info Type Code System#dawcode)
code: 7 (NCPDP Dispense As Written (DAW)/Product Selection Code#7)

supportingInfo
sequence: 4
category: Refill Number (C4BB Supporting Info Type Code System#refillnum)
value: 0

supportingInfo
sequence: 5
category: Refills Authorized (C4BB Supporting Info Type Code System#refillsauthorized)
value: 0

supportingInfo
sequence: 2
category: Brand Generic Indicator (C4BB Supporting Info Type Code System#brandgenericindicator)
code: 2 (NCPDP Brand Generic Indicator#2)

supportingInfo
sequence: 3
category: Rx Origin Code (C4BB Supporting Info Type Code System#rxorigincode)
code: 1 (NCPDP Prescription Origin Code#1)

supportingInfo
sequence: 7
category: Claim Received Date (C4BB Supporting Info Type Code System#clmrecvddate)
timing: 2019-10-31

supportingInfo
sequence: 9
category: Compound Code (C4BB Supporting Info Type Code System#compoundcode)
code: Dummy (NCPDP Compound Code#Dummy)

Insurances

-

Focal

Coverage

*

true

Coverage/Coverage3

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)
Amounts
- Value Currency
* 1000 USD
adjudication
category: Benefit Amount (Adjudication Value Codes#benefit)
Amounts
- Value Currency
* 20 USD
adjudication
category: Discount (C4BB Adjudication Code System#discount)
Amounts
- Value Currency
* 900 USD
adjudication
category: Member liability (C4BB Adjudication Code System#memberliability)
Amounts
- Value Currency
* 80 USD
adjudication
category: Paid to provider (C4BB Adjudication Code System#paidtoprovider)
Amounts
- Value Currency
* 20 USD

Adjudications

-

Category

Reason

*

Benefit Payment Status (C4BB Adjudication Discriminator Code System#benefitpaymentstatus)

In Network (C4BB Payer Adjudication Status Code System#innetwork)

*

Billing Network Status (C4BB Adjudication Discriminator Code System#billingnetworkstatus)

In Network (C4BB Payer Adjudication Status Code System#innetwork)

total
category: Payment Amount (C4BB Adjudication Code System#paidtoprovider)
Amounts
- Value Currency
* 620 USD

total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency
* 2650 USD

total
category: Patient Pay Amount (C4BB Adjudication Code System#paidbypatient)
Amounts
- Value Currency
* 0 USD

Notes:

Instance: EOBPharmacy1
InstanceOf: ExplanationOfBenefit
Title: "EOB Pharmacy Example1"
Description: "EOB Pharmacy Example1"
Usage: #example
* meta.lastUpdated = "2019-12-12T09:14:11+00:00"
* meta.profile = "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0"
* language = #en-US
* identifier.type = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType#uc
* identifier.system = "https://www.xxxplan.com/fhir/EOBIdentifier"
* identifier.value = "AW123412341234123412341234123412"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#pharmacy
  * text = "Pharmacy"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod.start = "2019-10-30"
* billablePeriod.end = "2019-10-31"
* created = "2019-07-02T00:00:00+00:00"
* insurer = Reference(Payer1) "XXX Health Plan"
* provider = Reference(ProviderOrganization1) "XXX Health Plan"
* outcome = #partial
* supportingInfo[0].sequence = 8
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dayssupply
* supportingInfo[=].valueQuantity.value = 30
* supportingInfo[+].sequence = 6
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#dawcode
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode#7
* supportingInfo[+].sequence = 4
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#refillnum
* supportingInfo[=].valueQuantity.value = 0
* supportingInfo[+].sequence = 5
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#refillsauthorized
* supportingInfo[=].valueQuantity.value = 0
* supportingInfo[+].sequence = 2
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#brandgenericindicator
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator#2
* supportingInfo[+].sequence = 3
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#rxorigincode
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode#1
* supportingInfo[+].sequence = 7
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#clmrecvddate
* supportingInfo[=].timingDate = "2019-10-31"
* supportingInfo[+].sequence = 9
* supportingInfo[=].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType#compoundcode
* supportingInfo[=].code = http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode#Dummy
* insurance.focal = true
* insurance.coverage = Reference(Coverage1)
* item.sequence = 1
* item.productOrService = http://hl7.org/fhir/sid/ndc#0777-3105-02 "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"
* item.servicedDate = "2019-07-02"
* item.adjudication[0].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
* item.adjudication[=].amount.value = 1000
* item.adjudication[=].amount.currency = #USD
* item.adjudication[+].category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
* item.adjudication[=].amount.value = 20
* item.adjudication[=].amount.currency = #USD
* item.adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#discount
* item.adjudication[=].amount.value = 900
* item.adjudication[=].amount.currency = #USD
* item.adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#memberliability
* item.adjudication[=].amount.value = 80
* item.adjudication[=].amount.currency = #USD
* item.adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* item.adjudication[=].amount.value = 20
* item.adjudication[=].amount.currency = #USD
* adjudication[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#benefitpaymentstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* adjudication[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator#billingnetworkstatus
* adjudication[=].reason = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus#innetwork
* total[0].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidtoprovider
* total[=].category.text = "Payment Amount"
* total[=].amount.value = 620
* total[=].amount.currency = #USD
* total[+].category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
  * text = "Submitted Amount"
* total[=].amount.value = 2650
* total[=].amount.currency = #USD
* total[+].category = http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication#paidbypatient
  * text = "Patient Pay Amount"
* total[=].amount.value = 0
* total[=].amount.currency = #USD

IG © 2022+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#2.0.0 based on FHIR 4.0.1. Generated 2022-11-28
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