CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.0.0 - STU1

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 1.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOBPharmacy1 - 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"
    ]
  },
  "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</b></p><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type pharmacy}\">Pharmacy</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Generated Summary: language: en-US; Member Number: 1234-234-1243-12345678901, Medical record number: 1234-234-1243-12345678901m, Unique Member ID: 1234-234-1243-12345678901u, Patient Account Number: 1234-234-1243-12345678901a; active; Johnny Example1 ; Phone: (301)666-1212; gender: male; birthDate: 1986-01-01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}\">unknown</span></a></p><p><b>billablePeriod</b>: 2019-10-30 --&gt; 2019-10-31</p><p><b>created</b>: Jul 2, 2019, 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Payer ID: 901234; active; name: Payer 1</a></p><p><b>provider</b>: <a href=\"Organization-OrganizationProvider1.html\">XXX Health Plan. Generated Summary: language: en-US; National Provider Identifier: 345678, Tax ID number: 123-45-6789; active; name: Provider 1</a></p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dayssupply}\">Days Supply</span></p><p><b>value</b>: 30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType dawcode}\">DAW (Dispense As Written) Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode 7}\">7</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType refillnum}\">Refill Number</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType billingnetworkcontractingstatus}\">Billing Network Contracting Status</span></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus contracted}\">Contracted</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType brandgenericcode}\">Brand Generic Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator 2}\">2</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType rxorigincode}\">Rx Origin Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/PrescriptionOriginCode 1}\">1</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}\">Claim Received Date</span></p><p><b>timing</b>: 2019-10-31</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType compoundcode}\">Compound Code</span></p><p><b>code</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/NCPDP/CompoundCode Dummy}\">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\">Generated Summary: language: en-US; Member Number: 1234-234-1243-12345678901; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span>; subscriberId: 12345678901; dependent: 01; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span>; period: 2019-01-01 --&gt; 2019-10-31; network: XYZ123-UPMC CONSUMER ADVA</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/ndc 0777-3105-02}\">100 CAPSULE in 1 BOTTLE (0777-3105-02)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication discount}\">Discount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication memberliability}\">Member liability</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}\">Paid to provider</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidtoprovider}\">Payment Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication paidbypatient}\">Patient Pay Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus innetwork}\">In Network</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</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/Patient1"
  },
  "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/OrganizationProvider1",
    "display" : "XXX Health Plan"
  },
  "outcome" : "partial",
  "supportingInfo" : [
    {
      "sequence" : 7,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 30
      }
    },
    {
      "sequence" : 5,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "dawcode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode",
            "code" : "7"
          }
        ]
      }
    },
    {
      "sequence" : 4,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "refillnum"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 0
      }
    },
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "billingnetworkcontractingstatus"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "contracted"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "brandgenericcode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator",
            "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/NCPDP/PrescriptionOriginCode",
            "code" : "1"
          }
        ]
      }
    },
    {
      "sequence" : 6,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "clmrecvddate"
          }
        ]
      },
      "timingDate" : "2019-10-31"
    },
    {
      "sequence" : 8,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code" : "compoundcode"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/NCPDP/CompoundCode",
            "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" : "100 CAPSULE in 1 BOTTLE (0777-3105-02)"
          }
        ]
      },
      "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"
          }
        }
      ]
    }
  ],
  "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"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code" : "innetwork"
          }
        ]
      },
      "amount" : {
        "value" : 0,
        "currency" : "USD"
      }
    }
  ]
}