CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1

This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: STU 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

Example ExplanationOfBenefit: EOBPharmacy1

Generated Narrative

identifier: Unique Claim ID: AW123412341234123412341234123412

status: active

type: Pharmacy

use: claim

patient: Generated Summary: language: en-US; Member Number: 1234-234-1243-12345678901, Medical record number: 1234-234-1243-12345678901m, Unique Member ID: 1234-234-1243-12345678901u, Patient Account Number: 1234-234-1243-12345678901a; active; Johnny Example1 ; Phone: (301)666-1212; gender: male; birthDate: 1986-01-01; unknown

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

created: Jul 2, 2019 12:00:00 AM

insurer: XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Payer ID: 901234; active; name: Payer 1

provider: XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Tax ID number: 123-45-6789; active; name: Provider 1

outcome: partial

supportingInfo

sequence: 7

category: Days Supply

value: 30

supportingInfo

sequence: 5

category: DAW (Dispense As Written) Code

code: 7

supportingInfo

sequence: 4

category: Refill Number

value: 0

supportingInfo

sequence: 1

category: Billing Network Contracting Status

code: Contracted

supportingInfo

sequence: 2

category: Brand Generic Code

code: 2

supportingInfo

sequence: 3

category: Rx Origin Code

code: 1

supportingInfo

sequence: 6

category: Claim Received Date

timing: 2019-10-31

supportingInfo

sequence: 8

category: Compound Code

code: Dummy

Insurances

-FocalCoverage
*trueGenerated Summary: language: en-US; Member Number: 1234-234-1243-12345678901; status: active; health insurance plan policy; subscriberId: 12345678901; dependent: 01; Self; period: 2019-01-01 --> 2019-10-31; network: XYZ123-UPMC CONSUMER ADVA

item

sequence: 1

productOrService: 100 CAPSULE in 1 BOTTLE (0777-3105-02)

adjudication

category: Submitted Amount

Amounts

-
*

adjudication

category: Benefit Amount

Amounts

-
*

adjudication

category: Discount

Amounts

-
*

adjudication

category: Member liability

Amounts

-
*

adjudication

category: Paid to provider

Amounts

-
*

total

category: Payment Amount

Amounts

-
*

total

category: Submitted Amount

Amounts

-
*

total

category: Patient Pay Amount

Amounts

-
*

total

category: In Network

Amounts

-
*

Notes:

FieldValue
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/NCPDP/DispensedAsWrittenOrProductSelectionCode"
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 #brandgenericcode
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/NCPDP/BrandGenericIndicator"
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/NCPDP/PrescriptionOriginCode"
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/NCPDP/CompoundCode"
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