CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.2.0 - STU 2.2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. 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

Page standards status: Informative

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EOBPharmacy1"/>
  <meta>
    <lastUpdated value="2019-12-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.2.0"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
      </coding>
    </type>
    <system value="https://www.example.com/fhir/EOBIdentifier"/>
    <value value="AW123412341234123412341234123412"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <version value="1.0.1"/>
      <code value="pharmacy"/>
    </coding>
    <text value="Pharmacy"/>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/Patient2"/>
  </patient>
  <billablePeriod>
    <start value="2019-10-30"/>
    <end value="2019-10-31"/>
  </billablePeriod>
  <created value="2019-07-02T00:00:00+00:00"/>
  <insurer>🔗 
    <reference value="Organization/Payer1"/>
    <display value="XXX Health Plan"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ProviderOrganization1"/>
    <display value="XXX Health Plan"/>
  </provider>
  <outcome value="partial"/>
  <supportingInfo>
    <sequence value="8"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="dayssupply"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="30"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="6"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="dawcode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode"/>
        <code value="7"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="4"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="refillnum"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="0"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="5"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="refillsauthorized"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="0"/>
    </valueQuantity>
  </supportingInfo>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="brandgenericindicator"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator"/>
        <code value="2"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="rxorigincode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode"/>
        <code value="1"/>
      </coding>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="7"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
      </coding>
    </category>
    <timingDate value="2019-10-31"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="9"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="compoundcode"/>
      </coding>
    </category>
    <code>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode"/>
        <code value="Dummy"/>
      </coding>
    </code>
  </supportingInfo>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/Coverage3"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/sid/ndc"/>
        <code value="0777-3105-02"/>
        <display
                 value="Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"/>
      </coding>
    </productOrService>
    <servicedDate value="2019-07-02"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <version value="1.0.1"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="1000"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <version value="1.0.1"/>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="20"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="discount"/>
        </coding>
      </category>
      <amount>
        <value value="900"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="memberliability"/>
        </coding>
      </category>
      <amount>
        <value value="80"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="paidtoprovider"/>
        </coding>
      </category>
      <amount>
        <value value="20"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="benefitpaymentstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
        <code value="billingnetworkstatus"/>
      </coding>
    </category>
    <reason>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="innetwork"/>
      </coding>
    </reason>
  </adjudication>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidtoprovider"/>
      </coding>
      <text value="Payment Amount"/>
    </category>
    <amount>
      <value value="620"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <version value="1.0.1"/>
        <code value="submitted"/>
      </coding>
      <text value="Submitted Amount"/>
    </category>
    <amount>
      <value value="2650"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="paidbypatient"/>
      </coding>
      <text value="Patient Pay Amount"/>
    </category>
    <amount>
      <value value="0"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>