CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.2.0 - STU 2 Pre-Publish United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.2.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Example ExplanationOfBenefit: EOBPharmacy1

Generated Narrative

Resource "EOBPharmacy1" Updated "2019-12-12 09:14:11+0000" (Language "en-US")

Profile: C4BB ExplanationOfBenefit Pharmacy (version 1.2.0)

identifier: Unique Claim ID: AW123412341234123412341234123412

status: active

type: Pharmacy (Claim Type Codes#pharmacy)

use: claim

patient: Patient/Patient1 " EXAMPLE1"

billablePeriod: 2019-10-30 --> 2019-10-31

created: 2019-07-02 12:00:00+0000

insurer: Organization/Payer1: XXX Health Plan "Payer 1"

provider: Organization/OrganizationProvider1: XXX Health Plan "Provider 1"

outcome: partial

supportingInfo

sequence: 8

category: Days Supply (C4BB Supporting Info Type#dayssupply)

value: 30

supportingInfo

sequence: 6

category: DAW (Dispense As Written) Code (C4BB Supporting Info Type#dawcode)

code: 7 (NCPDP Dispense As Written (DAW)/Product Selection Code#7)

supportingInfo

sequence: 4

category: Refill Number (C4BB Supporting Info Type#refillnum)

value: 0

supportingInfo

sequence: 5

category: Refills Authorized (C4BB Supporting Info Type#refillsauthorized)

value: 0

supportingInfo

sequence: 1

category: Billing Network Contracting Status (C4BB Supporting Info Type#billingnetworkcontractingstatus)

code: Contracted (C4BB Payer Adjudication Status#contracted)

supportingInfo

sequence: 2

category: Brand Generic Indicator (C4BB Supporting Info Type#brandgenericindicator)

code: 2 (NCPDP Brand Generic Indicator#2)

supportingInfo

sequence: 3

category: Rx Origin Code (C4BB Supporting Info Type#rxorigincode)

code: 1 (NCPDP Prescription Origin Code#1)

supportingInfo

sequence: 7

category: Claim Received Date (C4BB Supporting Info Type#clmrecvddate)

timing: 2019-10-31

supportingInfo

sequence: 9

category: Compound Code (C4BB Supporting Info Type#compoundcode)

code: Dummy (NCPDP Compound Code#Dummy)

supportingInfo

sequence: 10

category: In Network (C4BB Payer Adjudication Status#innetwork)

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

productOrService: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) (National drug codes#0777-3105-02)

serviced: 2019-07-02

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)

adjudication

category: Benefit Amount (Adjudication Value Codes#benefit)

adjudication

category: Discount (C4BB Adjudication#discount)

adjudication

category: Member liability (C4BB Adjudication#memberliability)

adjudication

category: Paid to provider (C4BB Adjudication#paidtoprovider)

total

category: Payment Amount (C4BB Adjudication#paidtoprovider)

total

category: Submitted Amount (Adjudication Value Codes#submitted)

total

category: Patient Pay Amount (C4BB Adjudication#paidbypatient)

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "EOBPharmacy1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy"
meta.lastUpdated "2019-12-12T09:14:11+00:00"
type.coding[0].code #pharmacy
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.text "Pharmacy"
use "claim"
supportingInfo[0].category.coding[0].code #dayssupply
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].sequence 7
supportingInfo[0].valueQuantity.value 30
supportingInfo[1].category.coding[0].code #dawcode
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].code.coding[0].code #7
supportingInfo[1].code.coding[0].system "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode"
supportingInfo[1].sequence 5
supportingInfo[2].category.coding[0].code #refillnum
supportingInfo[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[2].valueQuantity.value 0
supportingInfo[2].sequence 4
supportingInfo[3].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[3].sequence 1
supportingInfo[3].code.coding[0].code #contracted
supportingInfo[3].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[4].category.coding[0].code #brandgenericindicator
supportingInfo[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[4].sequence 2
supportingInfo[4].code.coding[0].code #2
supportingInfo[4].code.coding[0].system "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator"
supportingInfo[5].category.coding[0].code #rxorigincode
supportingInfo[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[5].code.coding[0].code #1
supportingInfo[5].code.coding[0].system "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode"
supportingInfo[5].sequence 3
supportingInfo[6].category.coding[0].code #clmrecvddate
supportingInfo[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[6].timingDate "2019-10-31"
supportingInfo[6].sequence 6
supportingInfo[7].category.coding[0].code #compoundcode
supportingInfo[7].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[7].code.coding[0].code #Dummy
supportingInfo[7].code.coding[0].system "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode"
supportingInfo[7].sequence 8
language "en-US"
status "active"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].value AW123412341234123412341234123412
identifier[0].system "https://www.xxxplan.com/fhir/EOBIdentifier"
created "2019-07-02T00:00:00+00:00"
insurer.reference "Organization/Payer1"
insurer.display "XXX Health Plan"
patient.reference "Patient/Patient1"
billablePeriod.start "2019-10-30"
billablePeriod.end "2019-10-31"
provider.reference "Organization/OrganizationProvider1"
provider.display "XXX Health Plan"
outcome "partial"
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/Coverage1"
total[0].category.coding[0].code #paidtoprovider
total[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[0].category.text "Payment Amount"
total[0].amount.value 620
total[0].amount.currency #USD
total[1].category.coding[0].code #submitted
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.text "Submitted Amount"
total[1].amount.value 2650
total[1].amount.currency #USD
total[2].category.coding[0].code #paidbypatient
total[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[2].category.text "Patient Pay Amount"
total[2].amount.value 0
total[2].amount.currency #USD
total[3].category.coding[0].code #innetwork
total[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
total[3].amount.value 0
total[3].amount.currency #USD
item[0].productOrService.coding[0].code #0777-3105-02
item[0].productOrService.coding[0].system "http://hl7.org/fhir/sid/ndc"
item[0].productOrService.coding[0].display "100 CAPSULE in 1 BOTTLE (0777-3105-02)"
item[0].sequence 1
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].amount.value 1000
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].code #benefit
item[0].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[1].amount.value 20
item[0].adjudication[1].amount.currency #USD
item[0].adjudication[2].category.coding[0].code #discount
item[0].adjudication[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[2].amount.value 900
item[0].adjudication[2].amount.currency #USD
item[0].adjudication[3].category.coding[0].code #memberliability
item[0].adjudication[3].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[3].amount.value 80
item[0].adjudication[3].amount.currency #USD
item[0].adjudication[4].category.coding[0].code #paidtoprovider
item[0].adjudication[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[4].amount.value 20
item[0].adjudication[4].amount.currency #USD