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## : SBC Benefit Category Code System - JSON Representation

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    {
      "resourceType" : "CodeSystem",
      "id" : "sbc-benefit-category",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem sbc-benefit-category</b></p><a name=\"sbc-benefit-category\"> </a><a name=\"hcsbc-benefit-category\"> </a><p>This case-sensitive code system <code>http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">preventive-care<a name=\"sbc-benefit-category-preventive-care\"> </a></td><td>Preventive Care/Screening/Immunization</td><td>Preventive care services, health screenings, and immunizations</td></tr><tr><td style=\"white-space:nowrap\">primary-care-visit<a name=\"sbc-benefit-category-primary-care-visit\"> </a></td><td>Primary Care Visit</td><td>Visits to primary care physicians to treat illness or injury</td></tr><tr><td style=\"white-space:nowrap\">specialist-visit<a name=\"sbc-benefit-category-specialist-visit\"> </a></td><td>Specialist Visit</td><td>Visits to specialist physicians</td></tr><tr><td style=\"white-space:nowrap\">diagnostic-test<a name=\"sbc-benefit-category-diagnostic-test\"> </a></td><td>Diagnostic Test</td><td>X-rays and diagnostic imaging other than CT/PET/MRI</td></tr><tr><td style=\"white-space:nowrap\">imaging<a name=\"sbc-benefit-category-imaging\"> </a></td><td>Imaging (CT/PET/MRI)</td><td>Advanced imaging services including CT scans, PET scans, and MRIs</td></tr><tr><td style=\"white-space:nowrap\">generic-drugs<a name=\"sbc-benefit-category-generic-drugs\"> </a></td><td>Generic Drugs</td><td>Generic prescription medications</td></tr><tr><td style=\"white-space:nowrap\">preferred-brand-drugs<a name=\"sbc-benefit-category-preferred-brand-drugs\"> </a></td><td>Preferred Brand Drugs</td><td>Brand-name prescription medications on the preferred drug list</td></tr><tr><td style=\"white-space:nowrap\">non-preferred-brand-drugs<a name=\"sbc-benefit-category-non-preferred-brand-drugs\"> </a></td><td>Non-Preferred Brand Drugs</td><td>Brand-name prescription medications not on the preferred drug list</td></tr><tr><td style=\"white-space:nowrap\">specialty-drugs<a name=\"sbc-benefit-category-specialty-drugs\"> </a></td><td>Specialty Drugs</td><td>High-cost or specialty prescription medications</td></tr><tr><td style=\"white-space:nowrap\">facility-fee<a name=\"sbc-benefit-category-facility-fee\"> </a></td><td>Facility Fee</td><td>Hospital or facility charges for services</td></tr><tr><td style=\"white-space:nowrap\">physician-surgeon-fee<a name=\"sbc-benefit-category-physician-surgeon-fee\"> </a></td><td>Physician/Surgeon Fees</td><td>Professional fees for physicians and surgeons</td></tr><tr><td style=\"white-space:nowrap\">emergency-room-care<a name=\"sbc-benefit-category-emergency-room-care\"> </a></td><td>Emergency Room Care</td><td>Emergency department services</td></tr><tr><td style=\"white-space:nowrap\">emergency-medical-transport<a name=\"sbc-benefit-category-emergency-medical-transport\"> </a></td><td>Emergency Medical Transportation</td><td>Ambulance and emergency medical transport services</td></tr><tr><td style=\"white-space:nowrap\">urgent-care<a name=\"sbc-benefit-category-urgent-care\"> </a></td><td>Urgent Care</td><td>Urgent care facility services</td></tr><tr><td style=\"white-space:nowrap\">hospital-outpatient<a name=\"sbc-benefit-category-hospital-outpatient\"> </a></td><td>Hospital Outpatient Care</td><td>Outpatient hospital services and surgeries</td></tr><tr><td style=\"white-space:nowrap\">hospital-inpatient<a name=\"sbc-benefit-category-hospital-inpatient\"> </a></td><td>Hospital Inpatient Care</td><td>Inpatient hospital stays and services</td></tr><tr><td style=\"white-space:nowrap\">mental-health-outpatient<a name=\"sbc-benefit-category-mental-health-outpatient\"> </a></td><td>Mental/Behavioral Health Outpatient Services</td><td>Outpatient mental health and substance abuse services</td></tr><tr><td style=\"white-space:nowrap\">mental-health-inpatient<a name=\"sbc-benefit-category-mental-health-inpatient\"> </a></td><td>Mental/Behavioral Health Inpatient Services</td><td>Inpatient mental health and substance abuse services</td></tr><tr><td style=\"white-space:nowrap\">pregnancy<a name=\"sbc-benefit-category-pregnancy\"> </a></td><td>Pregnancy Services</td><td>Prenatal and postnatal office visits</td></tr><tr><td style=\"white-space:nowrap\">pregnancy-delivery<a name=\"sbc-benefit-category-pregnancy-delivery\"> </a></td><td>Childbirth/Delivery Professional Services</td><td>Professional services for childbirth and delivery</td></tr><tr><td style=\"white-space:nowrap\">pregnancy-home-health<a name=\"sbc-benefit-category-pregnancy-home-health\"> </a></td><td>Pregnancy Home Health Care</td><td>Home health care services related to pregnancy</td></tr><tr><td style=\"white-space:nowrap\">rehabilitation<a name=\"sbc-benefit-category-rehabilitation\"> </a></td><td>Rehabilitation Services</td><td>Outpatient physical, occupational, and speech therapy</td></tr><tr><td style=\"white-space:nowrap\">habilitation<a name=\"sbc-benefit-category-habilitation\"> </a></td><td>Habilitation Services</td><td>Health care services that help develop or maintain daily living skills</td></tr><tr><td style=\"white-space:nowrap\">skilled-nursing<a name=\"sbc-benefit-category-skilled-nursing\"> </a></td><td>Skilled Nursing Care</td><td>Skilled nursing facility services</td></tr><tr><td style=\"white-space:nowrap\">durable-medical-equipment<a name=\"sbc-benefit-category-durable-medical-equipment\"> </a></td><td>Durable Medical Equipment</td><td>Medical equipment for home use such as wheelchairs, oxygen equipment</td></tr><tr><td style=\"white-space:nowrap\">hospice<a name=\"sbc-benefit-category-hospice\"> </a></td><td>Hospice Services</td><td>End-of-life care services</td></tr><tr><td style=\"white-space:nowrap\">children-eye-exam<a name=\"sbc-benefit-category-children-eye-exam\"> </a></td><td>Children's Eye Exam</td><td>Eye examinations for children</td></tr><tr><td style=\"white-space:nowrap\">children-glasses<a name=\"sbc-benefit-category-children-glasses\"> </a></td><td>Children's Glasses</td><td>Eyeglasses for children</td></tr><tr><td style=\"white-space:nowrap\">children-dental<a name=\"sbc-benefit-category-children-dental\"> </a></td><td>Children's Dental Check-up</td><td>Routine dental care for children</td></tr></table></div>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "claims"
        },
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
          "valueCode" : "informative",
          "_valueCode" : {
            "extension" : [
              {
                "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
                "valueCanonical" : "http://hl7.org/fhir/us/insurance-card/ImplementationGuide/hl7.fhir.us.insurance-card"
              }
            ]
          }
        }
      ],
      "url" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
      "identifier" : [
        {
          "system" : "urn:ietf:rfc:3986",
          "value" : "urn:oid:2.16.840.1.113883.4.642.40.9.16.5"
        }
      ],
      "version" : "2.0.0-ballot",
      "name" : "SBCBenefitCategoryCS",
      "title" : "SBC Benefit Category Code System",
      "status" : "draft",
      "experimental" : true,
      "date" : "2026-08-13T02:29:19+10:00",
      "publisher" : "HL7 International / Payer/Provider Information Exchange Work Group",
      "contact" : [
        {
          "name" : "HL7 International / Payer/Provider Information Exchange Work Group",
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/claims"
            },
            {
              "system" : "email",
              "value" : "pie@lists.HL7.org"
            }
          ]
        }
      ],
      "description" : "Code system for the 27 benefit categories required in Summary of Benefits and Coverage (SBC) documents per ACA Section 2715 regulations",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "US"
            }
          ]
        }
      ],
      "caseSensitive" : true,
      "content" : "complete",
      "count" : 29,
      "concept" : [
        {
          "code" : "preventive-care",
          "display" : "Preventive Care/Screening/Immunization",
          "definition" : "Preventive care services, health screenings, and immunizations"
        },
        {
          "code" : "primary-care-visit",
          "display" : "Primary Care Visit",
          "definition" : "Visits to primary care physicians to treat illness or injury"
        },
        {
          "code" : "specialist-visit",
          "display" : "Specialist Visit",
          "definition" : "Visits to specialist physicians"
        },
        {
          "code" : "diagnostic-test",
          "display" : "Diagnostic Test",
          "definition" : "X-rays and diagnostic imaging other than CT/PET/MRI"
        },
        {
          "code" : "imaging",
          "display" : "Imaging (CT/PET/MRI)",
          "definition" : "Advanced imaging services including CT scans, PET scans, and MRIs"
        },
        {
          "code" : "generic-drugs",
          "display" : "Generic Drugs",
          "definition" : "Generic prescription medications"
        },
        {
          "code" : "preferred-brand-drugs",
          "display" : "Preferred Brand Drugs",
          "definition" : "Brand-name prescription medications on the preferred drug list"
        },
        {
          "code" : "non-preferred-brand-drugs",
          "display" : "Non-Preferred Brand Drugs",
          "definition" : "Brand-name prescription medications not on the preferred drug list"
        },
        {
          "code" : "specialty-drugs",
          "display" : "Specialty Drugs",
          "definition" : "High-cost or specialty prescription medications"
        },
        {
          "code" : "facility-fee",
          "display" : "Facility Fee",
          "definition" : "Hospital or facility charges for services"
        },
        {
          "code" : "physician-surgeon-fee",
          "display" : "Physician/Surgeon Fees",
          "definition" : "Professional fees for physicians and surgeons"
        },
        {
          "code" : "emergency-room-care",
          "display" : "Emergency Room Care",
          "definition" : "Emergency department services"
        },
        {
          "code" : "emergency-medical-transport",
          "display" : "Emergency Medical Transportation",
          "definition" : "Ambulance and emergency medical transport services"
        },
        {
          "code" : "urgent-care",
          "display" : "Urgent Care",
          "definition" : "Urgent care facility services"
        },
        {
          "code" : "hospital-outpatient",
          "display" : "Hospital Outpatient Care",
          "definition" : "Outpatient hospital services and surgeries"
        },
        {
          "code" : "hospital-inpatient",
          "display" : "Hospital Inpatient Care",
          "definition" : "Inpatient hospital stays and services"
        },
        {
          "code" : "mental-health-outpatient",
          "display" : "Mental/Behavioral Health Outpatient Services",
          "definition" : "Outpatient mental health and substance abuse services"
        },
        {
          "code" : "mental-health-inpatient",
          "display" : "Mental/Behavioral Health Inpatient Services",
          "definition" : "Inpatient mental health and substance abuse services"
        },
        {
          "code" : "pregnancy",
          "display" : "Pregnancy Services",
          "definition" : "Prenatal and postnatal office visits"
        },
        {
          "code" : "pregnancy-delivery",
          "display" : "Childbirth/Delivery Professional Services",
          "definition" : "Professional services for childbirth and delivery"
        },
        {
          "code" : "pregnancy-home-health",
          "display" : "Pregnancy Home Health Care",
          "definition" : "Home health care services related to pregnancy"
        },
        {
          "code" : "rehabilitation",
          "display" : "Rehabilitation Services",
          "definition" : "Outpatient physical, occupational, and speech therapy"
        },
        {
          "code" : "habilitation",
          "display" : "Habilitation Services",
          "definition" : "Health care services that help develop or maintain daily living skills"
        },
        {
          "code" : "skilled-nursing",
          "display" : "Skilled Nursing Care",
          "definition" : "Skilled nursing facility services"
        },
        {
          "code" : "durable-medical-equipment",
          "display" : "Durable Medical Equipment",
          "definition" : "Medical equipment for home use such as wheelchairs, oxygen equipment"
        },
        {
          "code" : "hospice",
          "display" : "Hospice Services",
          "definition" : "End-of-life care services"
        },
        {
          "code" : "children-eye-exam",
          "display" : "Children's Eye Exam",
          "definition" : "Eye examinations for children"
        },
        {
          "code" : "children-glasses",
          "display" : "Children's Glasses",
          "definition" : "Eyeglasses for children"
        },
        {
          "code" : "children-dental",
          "display" : "Children's Dental Check-up",
          "definition" : "Routine dental care for children"
        }
      ]
    }