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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "EOBPharmacy1"] ; #
fhir:meta [
fhir:lastUpdated [ fhir:v "2019-12-12T09:14:11+00:00"^^xsd:dateTime ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.1.0"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.1.0> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit EOBPharmacy1</b></p><a name=\"EOBPharmacy1\"> </a><a name=\"hcEOBPharmacy1\"> </a><a name=\"EOBPharmacy1-en-US\"> </a><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\">Last updated: 2019-12-12 09:14:11+0000; Language: en-US</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Pharmacy.html\">C4BB ExplanationOfBenefit Pharmacyversion: null2.1.0)</a></p></div><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-Patient2.html\">Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)</a></p><p><b>billablePeriod</b>: 2019-10-30 --> 2019-10-31</p><p><b>created</b>: 2019-07-02 00:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">XXX Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">XXX Health Plan</a></p><p><b>outcome</b>: Partial Processing</p><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 dayssupply}\">Days Supply</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>: <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/NCPDPDispensedAsWrittenOrProductSelectionCode 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>: 5</p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType refillsauthorized}\">Refills Authorized</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>: <span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType brandgenericindicator}\">Brand Generic Indicator</span></p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator 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/NCPDPPrescriptionOriginCode 1}\">1</span></p></blockquote><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 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>: 9</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/NCPDPCompoundCode Dummy}\">Dummy</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-Coverage3.html\">Coverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; 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}\">Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)</span></p><p><b>serviced</b>: 2019-07-02</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1000</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>900</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>80</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator benefitpaymentstatus}\">Benefit Payment Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator billingnetworkstatus}\">Billing Network Status</span></td><td><span title=\"Codes:{http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></td></tr></table><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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>620</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2650</td><td>United States dollar</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 style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote></div>"^^rdf:XMLLiteral
] ; #
fhir:identifier ( [
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "uc" ] ] ) ] ;
fhir:system [ fhir:v "https://www.xxxplan.com/fhir/EOBIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "AW123412341234123412341234123412" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "pharmacy" ] ] ) ;
fhir:text [ fhir:v "Pharmacy" ]
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/Patient2" ]
] ; #
fhir:billablePeriod [
fhir:start [ fhir:v "2019-10-30"^^xsd:date ] ;
fhir:end [ fhir:v "2019-10-31"^^xsd:date ]
] ; #
fhir:created [ fhir:v "2019-07-02T00:00:00+00:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/Payer1" ] ;
fhir:display [ fhir:v "XXX Health Plan" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/ProviderOrganization1" ] ;
fhir:display [ fhir:v "XXX Health Plan" ]
] ; #
fhir:outcome [ fhir:v "partial"] ; #
fhir:supportingInfo ( [
fhir:sequence [ fhir:v "8"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "dayssupply" ] ] ) ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "30"^^xsd:decimal ] ]
] [
fhir:sequence [ fhir:v "6"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "dawcode" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "7" ] ] ) ]
] [
fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "refillnum" ] ] ) ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "0"^^xsd:decimal ] ]
] [
fhir:sequence [ fhir:v "5"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "refillsauthorized" ] ] ) ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "0"^^xsd:decimal ] ]
] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "brandgenericindicator" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ] ] ) ]
] [
fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "rxorigincode" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1" ] ] ) ]
] [
fhir:sequence [ fhir:v "7"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "clmrecvddate" ] ] ) ] ;
fhir:timing [
a fhir:date ;
fhir:v "2019-10-31"^^xsd:date ]
] [
fhir:sequence [ fhir:v "9"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "compoundcode" ] ] ) ] ;
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "Dummy" ] ] ) ]
] ) ; #
fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/Coverage3" ] ]
] ) ; #
fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/ndc"^^xsd:anyURI ] ;
fhir:code [ fhir:v "0777-3105-02" ] ;
fhir:display [ fhir:v "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)" ] ] ) ] ;
fhir:serviced [
a fhir:date ;
fhir:v "2019-07-02"^^xsd:date ] ;
( fhir:adjudication [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "1000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefit" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "discount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "900"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "memberliability" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "80"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidtoprovider" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] )
] ) ; #
fhir:adjudication ( [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefitpaymentstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "billingnetworkstatus" ] ] ) ] ;
fhir:reason [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ] ] ) ]
] ) ; #
fhir:total ( [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidtoprovider" ] ] ) ;
fhir:text [ fhir:v "Payment Amount" ] ] ;
fhir:amount [
fhir:value [ fhir:v "620"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ] ) ;
fhir:text [ fhir:v "Submitted Amount" ] ] ;
fhir:amount [
fhir:value [ fhir:v "2650"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ]
] [
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidbypatient" ] ] ) ;
fhir:text [ fhir:v "Patient Pay Amount" ] ] ;
fhir:amount [
fhir:value [ fhir:v "0"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ]
] ) . #
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.carin-bb#2.1.0 based on FHIR 4.0.1. Generated 2025-02-18
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