Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
0.1.0 - ci-build
Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
0.1.0 - ci-build
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
| Draft as of 2025-11-10 |
{
"resourceType" : "CodeSystem",
"id" : "sbc-benefit-category",
"text" : {
"status" : "generated",
"div" : "<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://flexpa.com/fhir/sbc/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>"
},
"url" : "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"version" : "0.1.0",
"name" : "SBCBenefitCategory",
"title" : "SBC Benefit Category Code System",
"status" : "draft",
"experimental" : false,
"date" : "2025-11-10T22:33:16+00:00",
"publisher" : "SBC FHIR Project",
"contact" : [
{
"name" : "SBC FHIR Project",
"telecom" : [
{
"system" : "url",
"value" : "http://flexpa.com"
},
{
"system" : "email",
"value" : "contact@flexpa.com"
}
]
}
],
"description" : "Code system for the 27 benefit categories required in Summary of Benefits and Coverage (SBC) documents per ACA Section 2715 regulations",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"caseSensitive" : true,
"content" : "complete",
"count" : 29,
"concept" : [
{
"code" : "preventive-care",
"display" : "Preventive Care/Screening/Immunization",
"definition" : "Preventive care services, health screenings, and immunizations"
},
{
"code" : "primary-care-visit",
"display" : "Primary Care Visit",
"definition" : "Visits to primary care physicians to treat illness or injury"
},
{
"code" : "specialist-visit",
"display" : "Specialist Visit",
"definition" : "Visits to specialist physicians"
},
{
"code" : "diagnostic-test",
"display" : "Diagnostic Test",
"definition" : "X-rays and diagnostic imaging other than CT/PET/MRI"
},
{
"code" : "imaging",
"display" : "Imaging (CT/PET/MRI)",
"definition" : "Advanced imaging services including CT scans, PET scans, and MRIs"
},
{
"code" : "generic-drugs",
"display" : "Generic Drugs",
"definition" : "Generic prescription medications"
},
{
"code" : "preferred-brand-drugs",
"display" : "Preferred Brand Drugs",
"definition" : "Brand-name prescription medications on the preferred drug list"
},
{
"code" : "non-preferred-brand-drugs",
"display" : "Non-Preferred Brand Drugs",
"definition" : "Brand-name prescription medications not on the preferred drug list"
},
{
"code" : "specialty-drugs",
"display" : "Specialty Drugs",
"definition" : "High-cost or specialty prescription medications"
},
{
"code" : "facility-fee",
"display" : "Facility Fee",
"definition" : "Hospital or facility charges for services"
},
{
"code" : "physician-surgeon-fee",
"display" : "Physician/Surgeon Fees",
"definition" : "Professional fees for physicians and surgeons"
},
{
"code" : "emergency-room-care",
"display" : "Emergency Room Care",
"definition" : "Emergency department services"
},
{
"code" : "emergency-medical-transport",
"display" : "Emergency Medical Transportation",
"definition" : "Ambulance and emergency medical transport services"
},
{
"code" : "urgent-care",
"display" : "Urgent Care",
"definition" : "Urgent care facility services"
},
{
"code" : "hospital-outpatient",
"display" : "Hospital Outpatient Care",
"definition" : "Outpatient hospital services and surgeries"
},
{
"code" : "hospital-inpatient",
"display" : "Hospital Inpatient Care",
"definition" : "Inpatient hospital stays and services"
},
{
"code" : "mental-health-outpatient",
"display" : "Mental/Behavioral Health Outpatient Services",
"definition" : "Outpatient mental health and substance abuse services"
},
{
"code" : "mental-health-inpatient",
"display" : "Mental/Behavioral Health Inpatient Services",
"definition" : "Inpatient mental health and substance abuse services"
},
{
"code" : "pregnancy",
"display" : "Pregnancy Services",
"definition" : "Prenatal and postnatal office visits"
},
{
"code" : "pregnancy-delivery",
"display" : "Childbirth/Delivery Professional Services",
"definition" : "Professional services for childbirth and delivery"
},
{
"code" : "pregnancy-home-health",
"display" : "Pregnancy Home Health Care",
"definition" : "Home health care services related to pregnancy"
},
{
"code" : "rehabilitation",
"display" : "Rehabilitation Services",
"definition" : "Outpatient physical, occupational, and speech therapy"
},
{
"code" : "habilitation",
"display" : "Habilitation Services",
"definition" : "Health care services that help develop or maintain daily living skills"
},
{
"code" : "skilled-nursing",
"display" : "Skilled Nursing Care",
"definition" : "Skilled nursing facility services"
},
{
"code" : "durable-medical-equipment",
"display" : "Durable Medical Equipment",
"definition" : "Medical equipment for home use such as wheelchairs, oxygen equipment"
},
{
"code" : "hospice",
"display" : "Hospice Services",
"definition" : "End-of-life care services"
},
{
"code" : "children-eye-exam",
"display" : "Children's Eye Exam",
"definition" : "Eye examinations for children"
},
{
"code" : "children-glasses",
"display" : "Children's Glasses",
"definition" : "Eyeglasses for children"
},
{
"code" : "children-dental",
"display" : "Children's Dental Check-up",
"definition" : "Routine dental care for children"
}
]
}