{
  "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|2.2.0"]
  },
  "language" : "en",
  "text" : {
    "status" : "generated"
  },
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
        "code" : "uc"
      }]
    },
    "system" : "https://www.example.com/fhir/EOBIdentifier",
    "value" : "AW123412341234123412341234123412"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "version" : "1.0.1",
      "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" : 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" : 5,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "refillsauthorized"
      }]
    },
    "valueQuantity" : {
      "value" : 0
    }
  },
  {
    "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/Coverage3"
    }
  }],
  "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",
          "version" : "1.0.1",
          "code" : "submitted"
        }]
      },
      "amount" : {
        "value" : 1000,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "version" : "1.0.1",
          "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",
        "version" : "1.0.1",
        "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"
    }
  }]
}