<status value="active" /> <experimental value="false" /> <date value="2024-01-01" /> <publisher value="b.Well Connected Health" /> <description value="EOB for Rx claims" /> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166" /> <code value="US" /> <display value="United States of America" /> </coding> <text value="United States of America" /> </jurisdiction> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="ExplanationOfBenefit" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit" /> <derivation value="constraint" /> <differential> <element id="ExplanationOfBenefit.id"> <path value="ExplanationOfBenefit.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.meta"> <path value="ExplanationOfBenefit.meta" /> <label value="meta" /> <min value="1" /> <type> <code value="Meta" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-meta" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.meta.security"> <path value="ExplanationOfBenefit.meta.security" /> <slicing> <description value="slice by system and code" /> <rules value="open" /> </slicing> <min value="2" /> </element> <element id="ExplanationOfBenefit.identifier"> <path value="ExplanationOfBenefit.identifier" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <min value="1" /> <type> <code value="Identifier" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-identifier" /> </type> </element> <element id="ExplanationOfBenefit.identifier:claim-number"> <path value="ExplanationOfBenefit.identifier" /> <sliceName value="claim-number" /> <short value="Unique claim identifier" /> <min value="1" /> <max value="1" /> <patternIdentifier> <type> <coding> <system value="https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type" /> <code value="claimnumber" /> </coding> <coding> <system value="https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type" /> <code value="Claim_Nbr" /> </coding> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" /> <code value="uc" /> <display value="Unique Claim ID" /> </coding> <text value="Claim Number" /> </type> </patternIdentifier> </element> <element id="ExplanationOfBenefit.identifier:prescription-number"> <path value="ExplanationOfBenefit.identifier" /> <sliceName value="prescription-number" /> <short value="The prescription identifier" /> <max value="1" /> <patternIdentifier> <type> <coding> <system value="https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type" /> <code value="RX" /> <display value="prescription number" /> </coding> </type> </patternIdentifier> </element> <element id="ExplanationOfBenefit.status"> <path value="ExplanationOfBenefit.status" /> <short value="Claim status" /> <comment value="default to active" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.type"> <path value="ExplanationOfBenefit.type" /> <short value="Claim type" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type" /> <code value="pharmacy" /> <display value="Pharmacy" /> </coding> </patternCodeableConcept> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.use"> <path value="ExplanationOfBenefit.use" /> <short value="Fixed: 'claim'" /> <fixedCode value="claim" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.patient"> <path value="ExplanationOfBenefit.patient" /> <short value="The patient receiving services" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-patient" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.patient.reference"> <path value="ExplanationOfBenefit.patient.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.created"> <path value="ExplanationOfBenefit.created" /> <definition value="The date this resource was created. This is sometimes the filled date of the prescription" /> <alias value="filled-date" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.enterer"> <path value="ExplanationOfBenefit.enterer" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.insurer"> <path value="ExplanationOfBenefit.insurer" /> <short value="Insurance company covering benefits" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-insurance-company" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurer.reference"> <path value="ExplanationOfBenefit.insurer.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.provider"> <path value="ExplanationOfBenefit.provider" /> <label value="pharmacy" /> <short value="Dispensing (billing) pharmacy" /> <alias value="billing-organization" /> <alias value="pharmacy" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.provider.reference"> <path value="ExplanationOfBenefit.provider.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.priority"> <path value="ExplanationOfBenefit.priority" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.fundsReserveRequested"> <path value="ExplanationOfBenefit.fundsReserveRequested" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.fundsReserve"> <path value="ExplanationOfBenefit.fundsReserve" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.referral"> <path value="ExplanationOfBenefit.referral" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.claim"> <path value="ExplanationOfBenefit.claim" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.claimResponse"> <path value="ExplanationOfBenefit.claimResponse" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.outcome"> <path value="ExplanationOfBenefit.outcome" /> <short value="complete | partial" /> <comment value="default to "complete"" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.preAuthRef"> <path value="ExplanationOfBenefit.preAuthRef" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.preAuthRefPeriod"> <path value="ExplanationOfBenefit.preAuthRefPeriod" /> <max value="0" /> </element> <element id="ExplanationOfBenefit.careTeam"> <path value="ExplanationOfBenefit.careTeam" /> <label value="care-team" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <short value="Providers listed on the claim" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.id"> <path value="ExplanationOfBenefit.careTeam.id" /> <short value="set as role code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.provider.reference"> <path value="ExplanationOfBenefit.careTeam.provider.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <short value="Indicator of the billing organization" /> <definition value=""True" for the party who is billing and/or responsible for the claimed products or services." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.careTeam.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="extensible" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-claim-care-team-role" /> </binding> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider"> <path value="ExplanationOfBenefit.careTeam" /> <sliceName value="pharmacy-provider" /> <short value="The pharmacy providing the prescription" /> <alias value="pharmacy" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.id"> <path value="ExplanationOfBenefit.careTeam.id" /> <min value="1" /> <fixedString value="billing" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <label value="care-team-pharmacy" /> <short value="Fixed: 1" /> <fixedPositiveInt value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-healthcare-organization" /> </type> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.provider.reference"> <path value="ExplanationOfBenefit.careTeam.provider.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <label value="care-team-pharmacy" /> <short value="Fixed value: True" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <label value="care-team-pharmacy" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.role.coding"> <path value="ExplanationOfBenefit.careTeam.role.coding" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.role.coding.id"> <path value="ExplanationOfBenefit.careTeam.role.coding.id" /> <min value="1" /> <fixedString value="billing" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.role.coding.system"> <path value="ExplanationOfBenefit.careTeam.role.coding.system" /> <min value="1" /> <fixedUri value="http://terminology.hl7.org/CodeSystem/claimcareteamrole" /> </element> <element id="ExplanationOfBenefit.careTeam:pharmacy-provider.role.coding.code"> <path value="ExplanationOfBenefit.careTeam.role.coding.code" /> <min value="1" /> <fixedCode value="billing" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider"> <path value="ExplanationOfBenefit.careTeam" /> <sliceName value="prescribing-provider" /> <short value="Practitioner who prescribed the product" /> <alias value="prescriber" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.id"> <path value="ExplanationOfBenefit.careTeam.id" /> <min value="1" /> <fixedString value="prescriber" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.sequence"> <path value="ExplanationOfBenefit.careTeam.sequence" /> <label value="prescribing-practitioner" /> <short value="Fixed value: 2" /> <fixedPositiveInt value="2" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.provider"> <path value="ExplanationOfBenefit.careTeam.provider" /> <short value="Prescribing practitioner" /> <alias value="precriber" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-practitioner" /> </type> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.provider.reference"> <path value="ExplanationOfBenefit.careTeam.provider.reference" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.responsible"> <path value="ExplanationOfBenefit.careTeam.responsible" /> <label value="prescribing-practitioner" /> <short value="Fixed value: True" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.role"> <path value="ExplanationOfBenefit.careTeam.role" /> <label value="prescribing-practitioner" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.role.coding"> <path value="ExplanationOfBenefit.careTeam.role.coding" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.role.coding.id"> <path value="ExplanationOfBenefit.careTeam.role.coding.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.role.coding.system"> <path value="ExplanationOfBenefit.careTeam.role.coding.system" /> <min value="1" /> <fixedUri value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" /> </element> <element id="ExplanationOfBenefit.careTeam:prescribing-provider.role.coding.code"> <path value="ExplanationOfBenefit.careTeam.role.coding.code" /> <min value="1" /> <fixedCode value="prescribing" /> </element> <element id="ExplanationOfBenefit.supportingInfo"> <path value="ExplanationOfBenefit.supportingInfo" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <short value="set to category code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.sequence"> <path value="ExplanationOfBenefit.supportingInfo.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.supportingInfo:days-supply"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="days-supply" /> <short value="Number of days supplied" /> <alias value="days-supply" /> <min value="1" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:days-supply.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> <fixedString value="dayssupply" /> </element> <element id="ExplanationOfBenefit.supportingInfo:days-supply.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <label value="days-supply" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="dayssupply" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:days-supply.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <min value="1" /> <type> <code value="Quantity" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:daw"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="daw" /> <short value="dispense as written" /> <definition value="Dispense as written description" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:daw.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:daw.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="dawcode" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:daw.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="brand-generic-indicator" /> <short value="Brand generic indicator" /> <definition value="NCPDP Brand Generic Indicator" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="brandgenericindicator" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="NCPDP Brand Generic Indicator code" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> </element> <element id="ExplanationOfBenefit.supportingInfo:brand-generic-indicator.value[x]:valueString"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <sliceName value="valueString" /> <label value="generic-brand" /> <min value="1" /> <type> <code value="string" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:prescribed-date"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="prescribed-date" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:prescribed-date.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:prescribed-date.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="https://www.icanbwell.com/CodeSystem/SupportingInfoType" /> <code value="prescribeddate" /> <display value="Prescribed Date" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:prescribed-date.timing[x]"> <path value="ExplanationOfBenefit.supportingInfo.timing[x]" /> <short value="Prescribed date" /> <min value="1" /> <type> <code value="date" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:compound-code"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="compound-code" /> <short value="NCPDP compound code" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:compound-code.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:compound-code.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="compoundcode" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:compound-code.code"> <path value="ExplanationOfBenefit.supportingInfo.code" /> <short value="NCPDP compound code" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:refill-number"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="refill-number" /> <short value="Refill number" /> <definition value="The instance of the refill" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:refill-number.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:refill-number.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="refillnum" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:refill-number.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <short value="The refill number value" /> <min value="1" /> <type> <code value="Quantity" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:refills-authorized"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="refills-authorized" /> <short value="Total number of refills authorized" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:refills-authorized.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:refills-authorized.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" /> <code value="refillsauthorized" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:refills-authorized.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <short value="The refills authorized value" /> <min value="1" /> <type> <code value="Quantity" /> </type> </element> <element id="ExplanationOfBenefit.supportingInfo:prescription-number"> <path value="ExplanationOfBenefit.supportingInfo" /> <sliceName value="prescription-number" /> <short value="The prescription number" /> <max value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:prescription-number.id"> <path value="ExplanationOfBenefit.supportingInfo.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.supportingInfo:prescription-number.category"> <path value="ExplanationOfBenefit.supportingInfo.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="https://www.icanbwell.com/CodeSystem/SupportingInfoType" /> <code value="prescriptionnumber" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.supportingInfo:prescription-number.value[x]"> <path value="ExplanationOfBenefit.supportingInfo.value[x]" /> <short value="The prescription number value" /> <min value="1" /> <type> <code value="Quantity" /> </type> </element> <element id="ExplanationOfBenefit.insurance"> <path value="ExplanationOfBenefit.insurance" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.id"> <path value="ExplanationOfBenefit.insurance.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.focal"> <path value="ExplanationOfBenefit.insurance.focal" /> <short value="Fixed: true" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.insurance.coverage"> <path value="ExplanationOfBenefit.insurance.coverage" /> <type> <code value="Reference" /> <targetProfile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-insurance-coverage" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item"> <path value="ExplanationOfBenefit.item" /> <short value="Product (drug) provided" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.id"> <path value="ExplanationOfBenefit.item.id" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.sequence"> <path value="ExplanationOfBenefit.item.sequence" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService"> <path value="ExplanationOfBenefit.item.productOrService" /> <slicing> <description value="slice by type" /> <rules value="open" /> </slicing> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.productOrService:ndc-code"> <path value="ExplanationOfBenefit.item.productOrService" /> <sliceName value="ndc-code" /> <short value="NDC code" /> <min value="1" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/ndc" /> </coding> </patternCodeableConcept> </element> <element id="ExplanationOfBenefit.item.serviced[x]"> <path value="ExplanationOfBenefit.item.serviced[x]" /> <short value="Filled date" /> <type> <code value="date" /> </type> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.quantity"> <path value="ExplanationOfBenefit.item.quantity" /> <short value="Amount dispensed" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication"> <path value="ExplanationOfBenefit.item.adjudication" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.item.adjudication.id"> <path value="ExplanationOfBenefit.item.adjudication.id" /> <min value="1" /> </element> <element id="ExplanationOfBenefit.item.adjudication.category"> <path value="ExplanationOfBenefit.item.adjudication.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <binding> <strength value="example" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-adjudication-category" /> </binding> </element> <element id="ExplanationOfBenefit.total"> <path value="ExplanationOfBenefit.total" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total.id"> <path value="ExplanationOfBenefit.total.id" /> <label value="eob-total" /> <short value="set to category code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.total.category"> <path value="ExplanationOfBenefit.total.category" /> <type> <code value="CodeableConcept" /> <profile value="https://fhir.icanbwell.com/4_0_0/StructureDefinition/de-codeable-concept" /> </type> <mustSupport value="true" /> <binding> <strength value="example" /> <valueSet value="https://fhir.icanbwell.com/4_0_0/ValueSet/vs-adjudication-category" /> </binding> </element> <element id="ExplanationOfBenefit.total.amount"> <path value="ExplanationOfBenefit.total.amount" /> <mustSupport value="true" /> </element> <element id="ExplanationOfBenefit.payment.date"> <path value="ExplanationOfBenefit.payment.date" /> <short value="Payment date" /> <mustSupport value="true" /> </element> </differential> </StructureDefinition>