CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
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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 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOB Pharmacy Example1 - JSON Representation

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "EOBPharmacy1",
  "meta" : {
    "lastUpdated" : "2019-12-12T09:14:11+00:00",
    "profile" : [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0"
    ]
  },
  "language" : "en-US",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBPharmacy1\"> </a></p><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\">Resource ExplanationOfBenefit \"EOBPharmacy1\" 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 Pharmacy (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient2.html\">Patient/Patient2</a> \" TEST\"</p><p><b>billablePeriod</b>: 2019-10-30 --&gt; 2019-10-31</p><p><b>created</b>: 2019-07-02 12:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">Organization/Payer1: XXX Health Plan</a> \"Organization Payer 1\"</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1: XXX Health Plan</a> \"Orange Medical Group\"</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Days Supply <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#dayssupply)</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>: DAW (Dispense As Written) Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#dawcode)</span></p><p><b>code</b>: 7 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPDispensedAsWrittenOrProductSelectionCode.html\">NCPDP Dispense As Written (DAW)/Product Selection Code</a>#7)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Refill Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#refillnum)</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>: Refills Authorized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#refillsauthorized)</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>: Brand Generic Indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#brandgenericindicator)</span></p><p><b>code</b>: 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPBrandGenericIndicator.html\">NCPDP Brand Generic Indicator</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Rx Origin Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#rxorigincode)</span></p><p><b>code</b>: 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPPrescriptionOriginCode.html\">NCPDP Prescription Origin Code</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#clmrecvddate)</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>: Compound Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type</a>#compoundcode)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-NCPDPCompoundCode.html\">NCPDP Compound Code</a>#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\">Coverage/Coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-v3-ndc.html\">National drug codes</a>#0777-3105-02)</span></p><p><b>serviced</b>: 2019-07-02</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1000</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#discount)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>900</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Member liability <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#memberliability)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>80</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Paid to provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>20</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td>Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator</a>#benefitpaymentstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#innetwork)</span></td></tr><tr><td>*</td><td>Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator</a>#billingnetworkstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status</a>#innetwork)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>620</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>2650</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication</a>#paidbypatient)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
  },
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code" : "uc"
          }
        ]
      },
      "system" : "https://www.xxxplan.com/fhir/EOBIdentifier",
      "value" : "AW123412341234123412341234123412"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ],
    "text" : "Pharmacy"
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/Patient2"
  },
  "billablePeriod" : {
    "start" : "2019-10-30",
    "end" : "2019-10-31"
  },
  "created" : "2019-07-02T00:00:00+00:00",
  "insurer" : {
    "reference" : "Organization/Payer1",
    "display" : "XXX Health Plan"
  },
  "provider" : {
    "reference" : "Organization/ProviderOrganization1",
    "display" : "XXX Health Plan"
  },
  "outcome" : "partial",
  "supportingInfo" : [
    {
      "sequence" : 8,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 30
      }
    },
    {
      "sequence" : 6,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "dawcode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode",
            "code" : "7"
          }
        ]
      }
    },
    {
      "sequence" : 4,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "refillnum"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 0
      }
    },
    {
      "sequence" : 5,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "refillsauthorized"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 0
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "brandgenericindicator"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator",
            "code" : "2"
          }
        ]
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "rxorigincode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode",
            "code" : "1"
          }
        ]
      }
    },
    {
      "sequence" : 7,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "clmrecvddate"
          }
        ]
      },
      "timingDate" : "2019-10-31"
    },
    {
      "sequence" : 9,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "compoundcode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode",
            "code" : "Dummy"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/Coverage1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/ndc",
            "code" : "0777-3105-02",
            "display" : "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"
          }
        ]
      },
      "servicedDate" : "2019-07-02",
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          },
          "amount" : {
            "value" : 1000,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "benefit"
              }
            ]
          },
          "amount" : {
            "value" : 20,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code" : "discount"
              }
            ]
          },
          "amount" : {
            "value" : 900,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code" : "memberliability"
              }
            ]
          },
          "amount" : {
            "value" : 80,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code" : "paidtoprovider"
              }
            ]
          },
          "amount" : {
            "value" : 20,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "adjudication" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "benefitpaymentstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code" : "billingnetworkstatus"
          }
        ]
      },
      "reason" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      }
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidtoprovider"
          }
        ],
        "text" : "Payment Amount"
      },
      "amount" : {
        "value" : 620,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted"
          }
        ],
        "text" : "Submitted Amount"
      },
      "amount" : {
        "value" : 2650,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code" : "paidbypatient"
          }
        ],
        "text" : "Patient Pay Amount"
      },
      "amount" : {
        "value" : 0,
        "currency" : "USD"
      }
    }
  ]
}