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

: 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|2.0.0"/>
  </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><b>Generated Narrative: ExplanationOfBenefit</b><a name="EOBPharmacy1"> </a></p><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">Resource ExplanationOfBenefit &quot;EOBPharmacy1&quot; Updated &quot;2019-12-12 09:14:11+0000&quot;  (Language &quot;en-US&quot;) </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-ExplanationOfBenefit-Pharmacy.html">C4BB ExplanationOfBenefit Pharmacy (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-Patient2.html">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>billablePeriod</b>: 2019-10-30 --&gt; 2019-10-31</p><p><b>created</b>: 2019-07-02 12:00:00+0000</p><p><b>insurer</b>: <a href="Organization-Payer1.html">Organization/Payer1: XXX Health Plan</a> &quot;Organization Payer 1&quot;</p><p><b>provider</b>: <a href="Organization-ProviderOrganization1.html">Organization/ProviderOrganization1: XXX Health Plan</a> &quot;Orange Medical Group&quot;</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Days Supply <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#dayssupply)</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>: DAW (Dispense As Written) Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#dawcode)</span></p><p><b>code</b>: 7 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPDispensedAsWrittenOrProductSelectionCode.html">NCPDP Dispense As Written (DAW)/Product Selection Code</a>#7)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Refill Number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#refillnum)</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>: Refills Authorized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#refillsauthorized)</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>: Brand Generic Indicator <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#brandgenericindicator)</span></p><p><b>code</b>: 2 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPBrandGenericIndicator.html">NCPDP Brand Generic Indicator</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Rx Origin Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#rxorigincode)</span></p><p><b>code</b>: 1 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPPrescriptionOriginCode.html">NCPDP Prescription Origin Code</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Claim Received Date <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#clmrecvddate)</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>: Compound Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBSupportingInfoType.html">C4BB Supporting Info Type Code System</a>#compoundcode)</span></p><p><b>code</b>: Dummy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPCompoundCode.html">NCPDP Compound Code</a>#Dummy)</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-Coverage3.html">Coverage/Coverage3</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-v3-ndc.html">National drug codes</a>#0777-3105-02)</span></p><p><b>serviced</b>: 2019-07-02</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1000</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#benefit)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication Code System</a>#discount)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>900</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Member liability <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication Code System</a>#memberliability)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>80</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Paid to provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td>Benefit Payment Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudicationDiscriminator.html">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></td><td>In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr><tr><td>*</td><td>Billing Network Status <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudicationDiscriminator.html">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></td><td>In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBPayerAdjudicationStatus.html">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>620</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>2650</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-C4BBAdjudication.html">C4BB Adjudication Code System</a>#paidbypatient)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</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>