Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required. |
identifier | S | 1..* | Identifier | Business Identifier for the resource |
type | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | |
created | S | 1..1 | dateTime | Response creation date |
careTeam | C | 0..* | BackboneElement | Care Team members EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization |
role | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required) | |
Slices for supportingInfo | 4..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category | |
supportingInfo:dayssupply | S | 1..1 | BackboneElement | Days supply |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dayssupply | |
value[x] | S | 1..1 | Quantity | Data to be provided |
supportingInfo:dawcode | S | 1..1 | BackboneElement | Dispense and written product selection code |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dawcode | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required) |
supportingInfo:refillNum | S | 1..1 | BackboneElement | The number fill of the claim dispensed supply |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: refillnum | |
value[x] | S | 1..1 | Quantity | Data to be provided |
supportingInfo:refillsAuthorized | 1..1 | BackboneElement | Number or refills authorized by prescriber | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: refillsauthorized | |
value[x] | S | 1..1 | Quantity | Data to be provided |
supportingInfo:brandgenericindicator | S | 0..1 | BackboneElement | Plan reported brand or generic drug indicator |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: brandgenericindicator | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NCPDP Brand Generic Indicator Value Set (required) |
supportingInfo:rxoriginCode | S | 0..1 | BackboneElement | Prescription origin code |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxorigincode | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NCPDP Prescription Origin Code Value Set (required) |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | S | 1..1 | date | When it occurred |
supportingInfo:compoundcode | S | 0..1 | BackboneElement | Code indicating whether or not the prescription is a compound |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: compoundcode | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NCPDP Compound Code Value Set (required) |
item | ||||
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: NDC or Compound Value Set (required) |
serviced[x] | 1..1 | date | Date or dates of service or product delivery Slice: Unordered, Open by type:$this | |
servicedDate | S | 1..1 | date | Date or dates of service or product delivery |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) | |
adjudication:adjudicationamounttype | S | 1..* | BackboneElement | Line level adjudication type and amount |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Value Set (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:rejectreason | S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rejectreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: NCPDP Reject Code Value Set (required) |
detail | S | 0..* | BackboneElement | Additional items |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: National Drug Code (NDC) Value Set (required) |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) |
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing provider networking status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required) |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required) |
Slices for total | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Total Category Discriminator Value Set (extensible) |
amount | S | 1..1 | Money | Financial total for the category |
total:adjudicationamounttype | S | 1..* | BackboneElement | Total adjudication type and amount |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Value Set (required) | |
amount | S | 1..1 | Money | Financial total for the category |
payment | ||||
date | S | 0..1 | date | Expected date of payment |
processNote | ||||
text | S | 0..1 | string | Note explanatory text |
Documentation for this format |