ExplanationOfBenefit - Pharmacy


Full Profile Definition: Profile: Explanation Of Benefit - Pharmacy


Resource Content:

Differential

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Hybrid

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id1..1stringFixed Value
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modifierExtensionΣ ?! I0..*Extension
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benefitPeriodI0..1Period
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1CodeableConcept
excluded0..1boolean
name0..1string
description0..1string
network0..1CodeableConcept
unit0..1CodeableConcept
term0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type1..1CodeableConcept
allowedUnsignedIntunsignedInt
allowedStringstring
allowedMoneyMoney
usedUnsignedIntunsignedInt
usedMoneyMoney



Examples:

{
    "resourceType": "ExplanationOfBenefit",
    "id": "3215698745682",
    "meta": {
        "source": "https://www.icanbwell.com",
        "profile":  [
            "https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-explanation-of-benefit-pharmacy"
        ],
        "security":  [
            {
                "system": "https://www.icanbwell.com/owner",
                "code": "bwell"
            },
            {
                "system": "https://www.icanbwell.com/access",
                "code": "bwell"
            }
        ]
    },
    "identifier":  [
        {
            "id": "claim-number",
            "type": {
                "coding":  [
                    {
                        "id": "claimnumber",
                        "system": "https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type",
                        "code": "claimnumber",
                        "display": "claim number"
                    },
                    {
                        "id": "claim_nbr",
                        "system": "https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type",
                        "code": "Claim_Nbr",
                        "display": "claim number"
                    },
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
                        "code": "uc",
                        "display": "Unique Claim ID"
                    }
                ],
                "text": "Claim Number"
            },
            "system": "https://www.icanbwell.com",
            "value": "3215698745682"
        },
        {
            "id": "prescription-number",
            "type": {
                "coding":  [
                    {
                        "id": "prescription-number-code",
                        "system": "https://fhir.icanbwell.com/4_0_0/CodeSystem/vs-identifier-type",
                        "code": "RX",
                        "display": "prescription number"
                    }
                ],
                "text": "Prescription number"
            },
            "system": "https://www.icanbwell.com",
            "value": "3215698745682"
        },
        {
            "id": "identifier-1",
            "type": {
                "coding":  [
                    {
                        "id": "identifier-1-type",
                        "system": "https://www.foo.com",
                        "code": "internal audit number",
                        "display": "internal audit number"
                    }
                ]
            },
            "system": "https://www.foo.com",
            "value": "A9254X9823RL"
        }
    ],
    "status": "active",
    "type": {
        "coding":  [
            {
                "id": "claim-type-code",
                "system": "http://terminology.hl7.org/CodeSystem/claim-type",
                "code": "pharmacy",
                "display": "pharmacy"
            }
        ],
        "text": "pharmacy"
    },
    "use": "claim",
    "patient": {
        "reference": "Patient/J555"
    },
    "billablePeriod": {
        "start": "2023-01-01T00:00:00.000Z",
        "end": "2023-01-01T00:00:00.000Z"
    },
    "created": "2023-01-01T00:00:00.000Z",
    "insurer": {
        "reference": "Organization/united"
    },
    "provider": {
        "reference": "Organization/1234567890|nppes"
    },
    "outcome": "complete",
    "careTeam":  [
        {
            "id": "billing-organization",
            "sequence": 1,
            "provider": {
                "reference": "Organization/1234567890|nppes"
            },
            "responsible": true,
            "role": {
                "coding":  [
                    {
                        "id": "billing",
                        "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
                        "code": "billing"
                    }
                ],
                "text": "Billing Organization"
            }
        },
        {
            "id": "prescriber",
            "sequence": 2,
            "provider": {
                "reference": "Practitioner/1122112211|nppes"
            },
            "responsible": false,
            "role": {
                "coding":  [
                    {
                        "id": "prescribing",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole",
                        "code": "prescribing"
                    }
                ],
                "text": "Prescribing Practitioner"
            }
        }
    ],
    "supportingInfo":  [
        {
            "id": "dayssupply",
            "sequence": 8,
            "category": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "dayssupply"
                    }
                ]
            },
            "valueQuantity": {
                "value": 30.0
            }
        },
        {
            "id": "dawcode",
            "sequence": 9,
            "category": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "dawcode"
                    }
                ]
            },
            "code": {
                "coding":  [
                    {
                        "id": "code",
                        "system": "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode",
                        "code": "0"
                    }
                ]
            }
        },
        {
            "id": "brandgenericindicator",
            "sequence": 12,
            "category": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "brandgenericindicator"
                    }
                ]
            },
            "code": {
                "coding":  [
                    {
                        "id": "code",
                        "system": "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator",
                        "code": "B"
                    }
                ]
            }
        },
        {
            "id": "refillNum",
            "sequence": 10,
            "category": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "refillnum"
                    }
                ]
            },
            "valueQuantity": {
                "value": 2.0
            }
        },
        {
            "id": "refillsAuthorized",
            "sequence": 11,
            "category": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "refillsauthorized"
                    }
                ]
            },
            "valueQuantity": {
                "value": 10.0
            }
        },
        {
            "id": "supportinginfo-prescribeddate",
            "sequence": 21,
            "category": {
                "coding":  [
                    {
                        "id": "category-code",
                        "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
                        "code": "info"
                    },
                    {
                        "id": "bwell",
                        "system": "https://www.icanbwell.com/CodeSystem/SupportingInfoType",
                        "code": "prescribeddate",
                        "display": "Prescribed Date"
                    }
                ]
            },
            "timingDate": "2023-01-01"
        },
        {
            "id": "supportinginfo-prescriptionnumber",
            "sequence": 20,
            "category": {
                "coding":  [
                    {
                        "id": "category-code",
                        "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
                        "code": "info"
                    },
                    {
                        "id": "bwell",
                        "system": "https://www.icanbwell.com/CodeSystem/SupportingInfoType",
                        "code": "prescriptionnumber",
                        "display": "Prescription Number"
                    }
                ]
            },
            "valueQuantity": {
                "value": 3215698690000.0
            }
        }
    ],
    "insurance":  [
        {
            "id": "insurance-1",
            "focal": true,
            "coverage": {
                "reference": "Coverage/J555-2023-01-01"
            }
        }
    ],
    "item":  [
        {
            "id": "1",
            "sequence": 1,
            "productOrService": {
                "coding":  [
                    {
                        "id": "ndc",
                        "system": "http://hl7.org/fhir/sid/ndc",
                        "code": "93083301"
                    }
                ],
                "text": "ClonazePAM"
            },
            "quantity": {
                "value": 1.0
            },
            "adjudication":  [
                {
                    "id": "benefit",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "benefit"
                            }
                        ]
                    },
                    "amount": {
                        "value": 130.0
                    }
                },
                {
                    "id": "copay",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "copay"
                            }
                        ]
                    },
                    "amount": {
                        "value": 20.0
                    }
                },
                {
                    "id": "memberliability",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "memberliability"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "benefit",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "benefit"
                            }
                        ]
                    },
                    "amount": {
                        "value": 130.0
                    }
                },
                {
                    "id": "allowed-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "allowed"
                            }
                        ]
                    },
                    "amount": {
                        "value": 130.0
                    }
                },
                {
                    "id": "eligible_amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "eligible"
                            }
                        ]
                    },
                    "amount": {
                        "value": 130.0
                    }
                },
                {
                    "id": "submitted_amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "submitted"
                            }
                        ]
                    },
                    "amount": {
                        "value": 150.0
                    }
                },
                {
                    "id": "deductible-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "deductible"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "noncovered_amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "noncovered"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "coinsurance",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "coinsurance"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "tax-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "tax"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "allowedunits",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
                                "code": "allowedunits"
                            }
                        ]
                    },
                    "value": 1.0
                },
                {
                    "id": "coinsurance",
                    "category": {
                        "coding":  [
                            {
                                "id": "category",
                                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                                "code": "coinsurance"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                }
            ]
        }
    ],
    "adjudication":  [
        {
            "id": "billingnetworkstatus",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
                        "code": "billingnetworkstatus"
                    }
                ]
            },
            "reason": {
                "coding":  [
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
                        "code": "innetwork"
                    }
                ]
            }
        }
    ],
    "total":  [
        {
            "id": "benefit",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "benefit"
                    }
                ]
            },
            "amount": {
                "value": 150.0
            }
        },
        {
            "id": "copay",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "copay"
                    }
                ]
            },
            "amount": {
                "value": 20.0
            }
        },
        {
            "id": "memberliability",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                        "code": "memberliability"
                    }
                ]
            },
            "amount": {
                "value": 20.0
            }
        },
        {
            "id": "allowed",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "code": "allowed"
                    }
                ]
            },
            "amount": {
                "value": 150.0
            }
        },
        {
            "id": "eligible",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "eligible"
                    }
                ]
            },
            "amount": {
                "value": 150.0
            }
        },
        {
            "id": "submitted",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "submitted"
                    }
                ]
            },
            "amount": {
                "value": 150.0
            }
        },
        {
            "id": "deductible",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "deductible"
                    }
                ]
            },
            "amount": {
                "value": 0.0
            }
        },
        {
            "id": "noncovered",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                        "code": "noncovered"
                    }
                ]
            },
            "amount": {
                "value": 0.0
            }
        },
        {
            "id": "coinsurance",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                        "code": "coinsurance"
                    }
                ]
            },
            "amount": {
                "value": 0.0
            }
        },
        {
            "id": "tax",
            "category": {
                "coding":  [
                    {
                        "id": "category",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "tax"
                    }
                ]
            },
            "amount": {
                "value": 0.0
            }
        }
    ],
    "benefitPeriod": {
        "start": "2023-01-01T00:00:00.000Z"
    }
}