CARIN Digital Insurance Card
2.0.0 - STU 2.0

CARIN Digital Insurance Card, published by HL7 International / Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-digital-insurance-card/ and changes regularly. See the Directory of published versions

## : SBC Benefit Category Code System - XML Representation

Page standards status: Informative

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    <CodeSystem xmlns="http://hl7.org/fhir">
      <id value="sbc-benefit-category"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem sbc-benefit-category</b></p><a name="sbc-benefit-category"> </a><a name="hcsbc-benefit-category"> </a><p>This case-sensitive code system <code>http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">preventive-care<a name="sbc-benefit-category-preventive-care"> </a></td><td>Preventive Care/Screening/Immunization</td><td>Preventive care services, health screenings, and immunizations</td></tr><tr><td style="white-space:nowrap">primary-care-visit<a name="sbc-benefit-category-primary-care-visit"> </a></td><td>Primary Care Visit</td><td>Visits to primary care physicians to treat illness or injury</td></tr><tr><td style="white-space:nowrap">specialist-visit<a name="sbc-benefit-category-specialist-visit"> </a></td><td>Specialist Visit</td><td>Visits to specialist physicians</td></tr><tr><td style="white-space:nowrap">diagnostic-test<a name="sbc-benefit-category-diagnostic-test"> </a></td><td>Diagnostic Test</td><td>X-rays and diagnostic imaging other than CT/PET/MRI</td></tr><tr><td style="white-space:nowrap">imaging<a name="sbc-benefit-category-imaging"> </a></td><td>Imaging (CT/PET/MRI)</td><td>Advanced imaging services including CT scans, PET scans, and MRIs</td></tr><tr><td style="white-space:nowrap">generic-drugs<a name="sbc-benefit-category-generic-drugs"> </a></td><td>Generic Drugs</td><td>Generic prescription medications</td></tr><tr><td style="white-space:nowrap">preferred-brand-drugs<a name="sbc-benefit-category-preferred-brand-drugs"> </a></td><td>Preferred Brand Drugs</td><td>Brand-name prescription medications on the preferred drug list</td></tr><tr><td style="white-space:nowrap">non-preferred-brand-drugs<a name="sbc-benefit-category-non-preferred-brand-drugs"> </a></td><td>Non-Preferred Brand Drugs</td><td>Brand-name prescription medications not on the preferred drug list</td></tr><tr><td style="white-space:nowrap">specialty-drugs<a name="sbc-benefit-category-specialty-drugs"> </a></td><td>Specialty Drugs</td><td>High-cost or specialty prescription medications</td></tr><tr><td style="white-space:nowrap">facility-fee<a name="sbc-benefit-category-facility-fee"> </a></td><td>Facility Fee</td><td>Hospital or facility charges for services</td></tr><tr><td style="white-space:nowrap">physician-surgeon-fee<a name="sbc-benefit-category-physician-surgeon-fee"> </a></td><td>Physician/Surgeon Fees</td><td>Professional fees for physicians and surgeons</td></tr><tr><td style="white-space:nowrap">emergency-room-care<a name="sbc-benefit-category-emergency-room-care"> </a></td><td>Emergency Room Care</td><td>Emergency department services</td></tr><tr><td style="white-space:nowrap">emergency-medical-transport<a name="sbc-benefit-category-emergency-medical-transport"> </a></td><td>Emergency Medical Transportation</td><td>Ambulance and emergency medical transport services</td></tr><tr><td style="white-space:nowrap">urgent-care<a name="sbc-benefit-category-urgent-care"> </a></td><td>Urgent Care</td><td>Urgent care facility services</td></tr><tr><td style="white-space:nowrap">hospital-outpatient<a name="sbc-benefit-category-hospital-outpatient"> </a></td><td>Hospital Outpatient Care</td><td>Outpatient hospital services and surgeries</td></tr><tr><td style="white-space:nowrap">hospital-inpatient<a name="sbc-benefit-category-hospital-inpatient"> </a></td><td>Hospital Inpatient Care</td><td>Inpatient hospital stays and services</td></tr><tr><td style="white-space:nowrap">mental-health-outpatient<a name="sbc-benefit-category-mental-health-outpatient"> </a></td><td>Mental/Behavioral Health Outpatient Services</td><td>Outpatient mental health and substance abuse services</td></tr><tr><td style="white-space:nowrap">mental-health-inpatient<a name="sbc-benefit-category-mental-health-inpatient"> </a></td><td>Mental/Behavioral Health Inpatient Services</td><td>Inpatient mental health and substance abuse services</td></tr><tr><td style="white-space:nowrap">pregnancy<a name="sbc-benefit-category-pregnancy"> </a></td><td>Pregnancy Services</td><td>Prenatal and postnatal office visits</td></tr><tr><td style="white-space:nowrap">pregnancy-delivery<a name="sbc-benefit-category-pregnancy-delivery"> </a></td><td>Childbirth/Delivery Professional Services</td><td>Professional services for childbirth and delivery</td></tr><tr><td style="white-space:nowrap">pregnancy-home-health<a name="sbc-benefit-category-pregnancy-home-health"> </a></td><td>Pregnancy Home Health Care</td><td>Home health care services related to pregnancy</td></tr><tr><td style="white-space:nowrap">rehabilitation<a name="sbc-benefit-category-rehabilitation"> </a></td><td>Rehabilitation Services</td><td>Outpatient physical, occupational, and speech therapy</td></tr><tr><td style="white-space:nowrap">habilitation<a name="sbc-benefit-category-habilitation"> </a></td><td>Habilitation Services</td><td>Health care services that help develop or maintain daily living skills</td></tr><tr><td style="white-space:nowrap">skilled-nursing<a name="sbc-benefit-category-skilled-nursing"> </a></td><td>Skilled Nursing Care</td><td>Skilled nursing facility services</td></tr><tr><td style="white-space:nowrap">durable-medical-equipment<a name="sbc-benefit-category-durable-medical-equipment"> </a></td><td>Durable Medical Equipment</td><td>Medical equipment for home use such as wheelchairs, oxygen equipment</td></tr><tr><td style="white-space:nowrap">hospice<a name="sbc-benefit-category-hospice"> </a></td><td>Hospice Services</td><td>End-of-life care services</td></tr><tr><td style="white-space:nowrap">children-eye-exam<a name="sbc-benefit-category-children-eye-exam"> </a></td><td>Children's Eye Exam</td><td>Eye examinations for children</td></tr><tr><td style="white-space:nowrap">children-glasses<a name="sbc-benefit-category-children-glasses"> </a></td><td>Children's Glasses</td><td>Eyeglasses for children</td></tr><tr><td style="white-space:nowrap">children-dental<a name="sbc-benefit-category-children-dental"> </a></td><td>Children's Dental Check-up</td><td>Routine dental care for children</td></tr></table></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="claims"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
        <valueCode value="informative">
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
            <valueCanonical
                            value="http://hl7.org/fhir/us/insurance-card/ImplementationGuide/hl7.fhir.us.insurance-card"/>
          </extension>
        </valueCode>
      </extension>
      <url
           value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
      <version value="2.0.0"/>
      <name value="SBCBenefitCategoryCS"/>
      <title value="SBC Benefit Category Code System"/>
      <status value="draft"/>
      <experimental value="true"/>
      <date value="2026-03-20T01:21:28+00:00"/>
      <publisher
                 value="HL7 International / Payer/Provider Information Exchange Work Group"/>
      <contact>
        <name
              value="HL7 International / Payer/Provider Information Exchange Work Group"/>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/claims"/>
        </telecom>
        <telecom>
          <system value="email"/>
          <value value="pie@lists.HL7.org"/>
        </telecom>
      </contact>
      <description
                   value="Code system for the 27 benefit categories required in Summary of Benefits and Coverage (SBC) documents per ACA Section 2715 regulations"/>
      <jurisdiction>
        <coding>
          <system value="urn:iso:std:iso:3166"/>
          <code value="US"/>
        </coding>
      </jurisdiction>
      <caseSensitive value="true"/>
      <content value="complete"/>
      <count value="29"/>
      <concept>
        <code value="preventive-care"/>
        <display value="Preventive Care/Screening/Immunization"/>
        <definition
                    value="Preventive care services, health screenings, and immunizations"/>
      </concept>
      <concept>
        <code value="primary-care-visit"/>
        <display value="Primary Care Visit"/>
        <definition
                    value="Visits to primary care physicians to treat illness or injury"/>
      </concept>
      <concept>
        <code value="specialist-visit"/>
        <display value="Specialist Visit"/>
        <definition value="Visits to specialist physicians"/>
      </concept>
      <concept>
        <code value="diagnostic-test"/>
        <display value="Diagnostic Test"/>
        <definition value="X-rays and diagnostic imaging other than CT/PET/MRI"/>
      </concept>
      <concept>
        <code value="imaging"/>
        <display value="Imaging (CT/PET/MRI)"/>
        <definition
                    value="Advanced imaging services including CT scans, PET scans, and MRIs"/>
      </concept>
      <concept>
        <code value="generic-drugs"/>
        <display value="Generic Drugs"/>
        <definition value="Generic prescription medications"/>
      </concept>
      <concept>
        <code value="preferred-brand-drugs"/>
        <display value="Preferred Brand Drugs"/>
        <definition
                    value="Brand-name prescription medications on the preferred drug list"/>
      </concept>
      <concept>
        <code value="non-preferred-brand-drugs"/>
        <display value="Non-Preferred Brand Drugs"/>
        <definition
                    value="Brand-name prescription medications not on the preferred drug list"/>
      </concept>
      <concept>
        <code value="specialty-drugs"/>
        <display value="Specialty Drugs"/>
        <definition value="High-cost or specialty prescription medications"/>
      </concept>
      <concept>
        <code value="facility-fee"/>
        <display value="Facility Fee"/>
        <definition value="Hospital or facility charges for services"/>
      </concept>
      <concept>
        <code value="physician-surgeon-fee"/>
        <display value="Physician/Surgeon Fees"/>
        <definition value="Professional fees for physicians and surgeons"/>
      </concept>
      <concept>
        <code value="emergency-room-care"/>
        <display value="Emergency Room Care"/>
        <definition value="Emergency department services"/>
      </concept>
      <concept>
        <code value="emergency-medical-transport"/>
        <display value="Emergency Medical Transportation"/>
        <definition value="Ambulance and emergency medical transport services"/>
      </concept>
      <concept>
        <code value="urgent-care"/>
        <display value="Urgent Care"/>
        <definition value="Urgent care facility services"/>
      </concept>
      <concept>
        <code value="hospital-outpatient"/>
        <display value="Hospital Outpatient Care"/>
        <definition value="Outpatient hospital services and surgeries"/>
      </concept>
      <concept>
        <code value="hospital-inpatient"/>
        <display value="Hospital Inpatient Care"/>
        <definition value="Inpatient hospital stays and services"/>
      </concept>
      <concept>
        <code value="mental-health-outpatient"/>
        <display value="Mental/Behavioral Health Outpatient Services"/>
        <definition
                    value="Outpatient mental health and substance abuse services"/>
      </concept>
      <concept>
        <code value="mental-health-inpatient"/>
        <display value="Mental/Behavioral Health Inpatient Services"/>
        <definition value="Inpatient mental health and substance abuse services"/>
      </concept>
      <concept>
        <code value="pregnancy"/>
        <display value="Pregnancy Services"/>
        <definition value="Prenatal and postnatal office visits"/>
      </concept>
      <concept>
        <code value="pregnancy-delivery"/>
        <display value="Childbirth/Delivery Professional Services"/>
        <definition value="Professional services for childbirth and delivery"/>
      </concept>
      <concept>
        <code value="pregnancy-home-health"/>
        <display value="Pregnancy Home Health Care"/>
        <definition value="Home health care services related to pregnancy"/>
      </concept>
      <concept>
        <code value="rehabilitation"/>
        <display value="Rehabilitation Services"/>
        <definition
                    value="Outpatient physical, occupational, and speech therapy"/>
      </concept>
      <concept>
        <code value="habilitation"/>
        <display value="Habilitation Services"/>
        <definition
                    value="Health care services that help develop or maintain daily living skills"/>
      </concept>
      <concept>
        <code value="skilled-nursing"/>
        <display value="Skilled Nursing Care"/>
        <definition value="Skilled nursing facility services"/>
      </concept>
      <concept>
        <code value="durable-medical-equipment"/>
        <display value="Durable Medical Equipment"/>
        <definition
                    value="Medical equipment for home use such as wheelchairs, oxygen equipment"/>
      </concept>
      <concept>
        <code value="hospice"/>
        <display value="Hospice Services"/>
        <definition value="End-of-life care services"/>
      </concept>
      <concept>
        <code value="children-eye-exam"/>
        <display value="Children's Eye Exam"/>
        <definition value="Eye examinations for children"/>
      </concept>
      <concept>
        <code value="children-glasses"/>
        <display value="Children's Glasses"/>
        <definition value="Eyeglasses for children"/>
      </concept>
      <concept>
        <code value="children-dental"/>
        <display value="Children's Dental Check-up"/>
        <definition value="Routine dental care for children"/>
      </concept>
    </CodeSystem>