CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 flag

This page is part of the CARIN Blue Button Implementation Guide (v2.1.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: EOB Pharmacy Example1

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit EOBPharmacy1

Last updated: 2019-12-12 09:14:11+0000; Language: en-US

Profile: C4BB ExplanationOfBenefit Pharmacyversion: null2.1.0)

identifier: Unique Claim ID/AW123412341234123412341234123412

status: Active

type: Pharmacy

use: Claim

patient: Member 01 Test Male, DoB: 1943-01-01 ( An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501)

billablePeriod: 2019-10-30 --> 2019-10-31

created: 2019-07-02 00:00:00+0000

insurer: XXX Health Plan

provider: XXX Health Plan

outcome: Partial Processing

supportingInfo

sequence: 8

category: Days Supply

value: 30

supportingInfo

sequence: 6

category: DAW (Dispense As Written) Code

code: 7

supportingInfo

sequence: 4

category: Refill Number

value: 0

supportingInfo

sequence: 5

category: Refills Authorized

value: 0

supportingInfo

sequence: 2

category: Brand Generic Indicator

code: 2

supportingInfo

sequence: 3

category: Rx Origin Code

code: 1

supportingInfo

sequence: 7

category: Claim Received Date

timing: 2019-10-31

supportingInfo

sequence: 9

category: Compound Code

code: Dummy

Insurances

-FocalCoverage
*trueCoverage: identifier = Member Number; status = active; type = health insurance plan policy; subscriberId = 12345678901; dependent = 01; relationship = Self; period = 2019-01-01 --> 2019-10-31; network = XYZ123-UPMC CONSUMER ADVA

item

sequence: 1

productOrService: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)

serviced: 2019-07-02

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*1000United States dollar

adjudication

category: Benefit Amount

Amounts

-ValueCurrency
*20United States dollar

adjudication

category: Discount

Amounts

-ValueCurrency
*900United States dollar

adjudication

category: Member liability

Amounts

-ValueCurrency
*80United States dollar

adjudication

category: Paid to provider

Amounts

-ValueCurrency
*20United States dollar

Adjudications

-CategoryReason
*Benefit Payment StatusIn Network
*Billing Network StatusIn Network

total

category: Payment Amount

Amounts

-ValueCurrency
*620United States dollar

total

category: Submitted Amount

Amounts

-ValueCurrency
*2650United States dollar

total

category: Patient Pay Amount

Amounts

-ValueCurrency
*0United States dollar

Notes:

Instance: EOBPharmacy1
InstanceOf: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.1.0
Title: "EOB Pharmacy Example1"
Description: "EOB Pharmacy Example1"
Usage: #example
* meta.lastUpdated = "2019-12-12T09:14:11+00:00"
* language = #en-US
* identifier
  * type = C4BBIdentifierType#uc
  * system = "https://www.xxxplan.com/fhir/EOBIdentifier"
  * value = "AW123412341234123412341234123412"
* status = #active
* type = http://terminology.hl7.org/CodeSystem/claim-type#pharmacy
  * text = "Pharmacy"
* use = #claim
* patient = Reference(Patient2)
* billablePeriod
  * start = "2019-10-30"
  * end = "2019-10-31"
* created = "2019-07-02T00:00:00+00:00"
* insurer = Reference(Payer1) "XXX Health Plan"
* provider = Reference(ProviderOrganization1) "XXX Health Plan"
* outcome = #partial
* supportingInfo[0]
  * sequence = 8
  * category = C4BBSupportingInfoType#dayssupply
  * valueQuantity.value = 30
* supportingInfo[+]
  * sequence = 6
  * category = C4BBSupportingInfoType#dawcode
  * code = http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode#7
* supportingInfo[+]
  * sequence = 4
  * category = C4BBSupportingInfoType#refillnum
  * valueQuantity.value = 0
* supportingInfo[+]
  * sequence = 5
  * category = C4BBSupportingInfoType#refillsauthorized
  * valueQuantity.value = 0
* supportingInfo[+]
  * sequence = 2
  * category = C4BBSupportingInfoType#brandgenericindicator
  * code = http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator#2
* supportingInfo[+]
  * sequence = 3
  * category = C4BBSupportingInfoType#rxorigincode
  * code = http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode#1
* supportingInfo[+]
  * sequence = 7
  * category = C4BBSupportingInfoType#clmrecvddate
  * timingDate = "2019-10-31"
* supportingInfo[+]
  * sequence = 9
  * category = C4BBSupportingInfoType#compoundcode
  * code = http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode#Dummy
* insurance
  * focal = true
  * coverage = Reference(Coverage3)
* item
  * sequence = 1
  * productOrService = http://hl7.org/fhir/sid/ndc#0777-3105-02 "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"
  * servicedDate = "2019-07-02"
  * adjudication[0]
    * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
    * amount
      * value = 1000
      * currency = #USD
  * adjudication[+]
    * category = http://terminology.hl7.org/CodeSystem/adjudication#benefit
    * amount
      * value = 20
      * currency = #USD
  * adjudication[+]
    * category = C4BBAdjudication#discount
    * amount
      * value = 900
      * currency = #USD
  * adjudication[+]
    * category = C4BBAdjudication#memberliability
    * amount
      * value = 80
      * currency = #USD
  * adjudication[+]
    * category = C4BBAdjudication#paidtoprovider
    * amount
      * value = 20
      * currency = #USD
* adjudication[0]
  * category = C4BBAdjudicationDiscriminator#benefitpaymentstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* adjudication[+]
  * category = C4BBAdjudicationDiscriminator#billingnetworkstatus
  * reason = C4BBPayerAdjudicationStatus#innetwork
* total[0]
  * category = C4BBAdjudication#paidtoprovider
    * text = "Payment Amount"
  * amount
    * value = 620
    * currency = #USD
* total[+]
  * category = http://terminology.hl7.org/CodeSystem/adjudication#submitted
    * text = "Submitted Amount"
  * amount
    * value = 2650
    * currency = #USD
* total[+]
  * category = C4BBAdjudication#paidbypatient
    * text = "Patient Pay Amount"
  * amount
    * value = 0
    * currency = #USD