CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1
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 
{
"resourceType" : "ExplanationOfBenefit",
"id" : "EOBPharmacy1",
"meta" : {
"lastUpdated" : "2019-12-12T09:14:11+00:00",
"profile" : [
"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative</b></p><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-Patient1.html\">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; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}\">unknown</span></a></p><p><b>billablePeriod</b>: 2019-10-30 --> 2019-10-31</p><p><b>created</b>: Jul 2, 2019 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Payer ID: 901234; active; name: Payer 1</a></p><p><b>provider</b>: <a href=\"Organization-OrganizationProvider1.html\">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Tax ID number: 123-45-6789; active; name: Provider 1</a></p><p><b>outcome</b>: partial</p><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 dayssupply}\">Days Supply</span></p><p><b>value</b>: 30</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 dawcode}\">DAW (Dispense As Written) Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode 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>: 1</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType billingnetworkcontractingstatus}\">Billing Network Contracting Status</span></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus contracted}\">Contracted</span></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 brandgenericcode}\">Brand Generic Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator 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/NCPDP/PrescriptionOriginCode 1}\">1</span></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 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>: 8</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/NCPDP/CompoundCode Dummy}\">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-Coverage1.html\">Generated Summary: language: en-US; Member Number: 1234-234-1243-12345678901; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span>; subscriberId: 12345678901; dependent: 01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span>; period: 2019-01-01 --> 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}\">100 CAPSULE in 1 BOTTLE (0777-3105-02)</span></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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</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>-</td></tr><tr><td>*</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/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
"code" : "uc"
}
]
},
"system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
"value" : "AW123412341234123412341234123412"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "pharmacy"
}
],
"text" : "Pharmacy"
},
"use" : "claim",
"patient" : {
"reference" : "Patient/Patient1"
},
"billablePeriod" : {
"start" : "2019-10-30",
"end" : "2019-10-31"
},
"created" : "2019-07-02T00:00:00+00:00",
"insurer" : {
"reference" : "Organization/Payer1",
"display" : "XXX Health Plan"
},
"provider" : {
"reference" : "Organization/OrganizationProvider1",
"display" : "XXX Health Plan"
},
"outcome" : "partial",
"supportingInfo" : [
{
"sequence" : 7,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "dayssupply"
}
]
},
"valueQuantity" : {
"value" : 30
}
},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "dawcode"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode",
"code" : "7"
}
]
}
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "refillnum"
}
]
},
"valueQuantity" : {
"value" : 0
}
},
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "billingnetworkcontractingstatus"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "contracted"
}
]
}
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "brandgenericcode"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator",
"code" : "2"
}
]
}
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "rxorigincode"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/NCPDP/PrescriptionOriginCode",
"code" : "1"
}
]
}
},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "clmrecvddate"
}
]
},
"timingDate" : "2019-10-31"
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
"code" : "compoundcode"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/NCPDP/CompoundCode",
"code" : "Dummy"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/Coverage1"
}
}
],
"item" : [
{
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/ndc",
"code" : "0777-3105-02",
"display" : "100 CAPSULE in 1 BOTTLE (0777-3105-02)"
}
]
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 1000,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 20,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "discount"
}
]
},
"amount" : {
"value" : 900,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "memberliability"
}
]
},
"amount" : {
"value" : 80,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
]
},
"amount" : {
"value" : 20,
"currency" : "USD"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidtoprovider"
}
],
"text" : "Payment Amount"
},
"amount" : {
"value" : 620,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
],
"text" : "Submitted Amount"
},
"amount" : {
"value" : 2650,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"code" : "paidbypatient"
}
],
"text" : "Patient Pay Amount"
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
"code" : "innetwork"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
}
]
}
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#1.0.0 based on FHIR 4.0.1. Generated 2020-11-23
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