Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
0.1.0 - ci-build United States of America

Summary of Benefits and Coverage (SBC) FHIR Implementation Guide, published by SBC FHIR Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/jdjkelly/fhir-sbc/ and changes regularly. See the Directory of published versions

CodeSystem: SBC Benefit Category Code System

Official URL: http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category Version: 0.1.0
Draft as of 2026-02-16 Computable Name: SBCBenefitCategoryCS

Code system for the 30 benefit service rows required in Summary of Benefits and Coverage (SBC) documents per ACA Section 2715 regulations

This Code system is referenced in the content logical definition of the following value sets:

This case-sensitive code system http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category defines the following codes:

CodeDisplayDefinition
primary-care-visit Primary Care Visit to Treat an Injury or Illness Visits to primary care physicians to treat illness or injury
specialist-visit Specialist Visit Visits to specialist physicians
preventive-care Preventive Care/Screening/Immunization Preventive care services, health screenings, and immunizations
diagnostic-test Diagnostic Test (X-ray, Blood Work) X-rays, blood work, and other diagnostic tests
imaging Imaging (CT/PET Scans, MRIs) Advanced imaging services including CT scans, PET scans, and MRIs
generic-drugs Generic Drugs Generic prescription medications
preferred-brand-drugs Preferred Brand Drugs Brand-name prescription medications on the preferred drug list
non-preferred-brand-drugs Non-Preferred Brand Drugs Brand-name prescription medications not on the preferred drug list
specialty-drugs Specialty Drugs High-cost or specialty prescription medications
outpatient-facility-fee Facility Fee (e.g., Ambulatory Surgery Center) Facility charges for outpatient surgery
outpatient-physician-fee Physician/Surgeon Fees (Outpatient Surgery) Professional fees for physicians and surgeons for outpatient surgery
emergency-room-care Emergency Room Care Emergency department services
emergency-medical-transport Emergency Medical Transportation Ambulance and emergency medical transport services
urgent-care Urgent Care Urgent care facility services
hospital-facility-fee Facility Fee (e.g., Hospital Room) Facility charges for hospital inpatient stays
hospital-physician-fee Physician/Surgeon Fees (Hospital Stay) Professional fees for physicians and surgeons during hospital stays
mental-health-outpatient Mental/Behavioral Health Outpatient Services Outpatient mental health and substance abuse services
mental-health-inpatient Mental/Behavioral Health Inpatient Services Inpatient mental health and substance abuse services
pregnancy-office-visits Office Visits (Pregnancy) Prenatal and postnatal office visits
pregnancy-delivery-professional Childbirth/Delivery Professional Services Professional services for childbirth and delivery
pregnancy-delivery-facility Childbirth/Delivery Facility Services Facility services for childbirth and delivery
home-health-care Home Health Care Home health care services
rehabilitation Rehabilitation Services Outpatient physical, occupational, and speech therapy
habilitation Habilitation Services Health care services that help develop or maintain daily living skills
skilled-nursing Skilled Nursing Care Skilled nursing facility services
durable-medical-equipment Durable Medical Equipment Medical equipment for home use such as wheelchairs, oxygen equipment
hospice Hospice Services End-of-life care services
children-eye-exam Children's Eye Exam Eye examinations for children
children-glasses Children's Glasses Eyeglasses for children
children-dental Children's Dental Check-up Routine dental care for children