Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
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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 2025-11-10 Computable Name: SBCBenefitCategory

Code system for the 27 benefit categories 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
preventive-care Preventive Care/Screening/Immunization Preventive care services, health screenings, and immunizations
primary-care-visit Primary Care Visit Visits to primary care physicians to treat illness or injury
specialist-visit Specialist Visit Visits to specialist physicians
diagnostic-test Diagnostic Test X-rays and diagnostic imaging other than CT/PET/MRI
imaging Imaging (CT/PET/MRI) 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
facility-fee Facility Fee Hospital or facility charges for services
physician-surgeon-fee Physician/Surgeon Fees Professional fees for physicians and surgeons
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-outpatient Hospital Outpatient Care Outpatient hospital services and surgeries
hospital-inpatient Hospital Inpatient Care Inpatient hospital stays and services
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 Pregnancy Services Prenatal and postnatal office visits
pregnancy-delivery Childbirth/Delivery Professional Services Professional services for childbirth and delivery
pregnancy-home-health Pregnancy Home Health Care Home health care services related to pregnancy
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