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 
<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"/>
</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</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>
</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/Patient1"/>
</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/OrganizationProvider1"/>
<display value="XXX Health Plan"/>
</provider>
<outcome value="partial"/>
<supportingInfo>
<sequence value="7"/>
<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="5"/>
<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/NCPDP/DispensedAsWrittenOrProductSelectionCode"/>
<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="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="billingnetworkcontractingstatus"/>
</coding>
</category>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="contracted"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
<code value="brandgenericcode"/>
</coding>
</category>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator"/>
<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/NCPDP/PrescriptionOriginCode"/>
<code value="1"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<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="8"/>
<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/NCPDP/CompoundCode"/>
<code value="Dummy"/>
</coding>
</code>
</supportingInfo>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/Coverage1"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://hl7.org/fhir/sid/ndc"/>
<code value="0777-3105-02"/>
<display value="100 CAPSULE in 1 BOTTLE (0777-3105-02)"/>
</coding>
</productOrService>
<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>
<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>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
<code value="innetwork"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>
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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