FHIRsmith: ExplanationOfBenefit/ExplanationOfBenefit-EOBPharmacy1.json

FHIR IG analytics

Package	hl7.fhir.us.carin-bb
Resource Type	ExplanationOfBenefit
Id	ExplanationOfBenefit-EOBPharmacy1.json
FHIR Version	R4

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: ExplanationOfBenefit EOBPharmacy1

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

Profile: C4BB ExplanationOfBenefit Pharmacyversion: null2.2.0)

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: 2
category: Brand Generic Indicator
code: 2

supportingInfo
sequence: 3
category: Rx Origin Code
code: 1

supportingInfo
sequence: 5
category: Refills Authorized
value: 0

supportingInfo
sequence: 7
category: Claim Received Date
timing: 2019-10-31

supportingInfo
sequence: 9
category: Compound Code
code: Dummy

Insurances

Focal

Coverage

true

Coverage: 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
- Value Currency
* 1000 United States dollar
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 20 United States dollar
adjudication
category: Discount
Amounts
- Value Currency
* 900 United States dollar
adjudication
category: Member liability
Amounts
- Value Currency
* 80 United States dollar
adjudication
category: Paid to provider
Amounts
- Value Currency
* 20 United States dollar

Adjudications

Category

Reason

Benefit Payment Status

In Network

Billing Network Status

In Network

total
category: Payment Amount
Amounts
- Value Currency
* 620 United States dollar

total
category: Submitted Amount
Amounts
- Value Currency
* 2650 United States dollar

total
category: Patient Pay Amount
Amounts
- Value Currency
* 0 United States dollar

Source1

{
  "resourceType": "ExplanationOfBenefit",
  "id": "EOBPharmacy1",
  "meta": {
    "lastUpdated": "2019-12-12T09:14:11+00:00",
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.2.0"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
            "code": "uc"
          }
        ]
      },
      "system": "https://www.example.com/fhir/EOBIdentifier",
      "value": "AW123412341234123412341234123412"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "version": "1.0.1",
        "code": "pharmacy"
      }
    ],
    "text": "Pharmacy"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/Patient2"
  },
  "billablePeriod": {
    "start": "2019-10-30",
    "end": "2019-10-31"
  },
  "created": "2019-07-02T00:00:00+00:00",
  "insurer": {
    "reference": "Organization/Payer1",
    "display": "XXX Health Plan"
  },
  "provider": {
    "reference": "Organization/ProviderOrganization1",
    "display": "XXX Health Plan"
  },
  "outcome": "partial",
  "supportingInfo": [
    {
      "sequence": 8,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "dayssupply"
          }
        ]
      },
      "valueQuantity": {
        "value": 30
      }
    },
    {
      "sequence": 6,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "dawcode"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode",
            "code": "7"
          }
        ]
      }
    },
    {
      "sequence": 4,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "refillnum"
          }
        ]
      },
      "valueQuantity": {
        "value": 0
      }
    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "brandgenericindicator"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator",
            "code": "2"
          }
        ]
      }
    },
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "rxorigincode"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode",
            "code": "1"
          }
        ]
      }
    },
    {
      "sequence": 5,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "refillsauthorized"
          }
        ]
      },
      "valueQuantity": {
        "value": 0
      }
    },
    {
      "sequence": 7,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "clmrecvddate"
          }
        ]
      },
      "timingDate": "2019-10-31"
    },
    {
      "sequence": 9,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "compoundcode"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode",
            "code": "Dummy"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/Coverage3"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/ndc",
            "code": "0777-3105-02",
            "display": "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)"
          }
        ]
      },
      "servicedDate": "2019-07-02",
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "version": "1.0.1",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 1000,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "version": "1.0.1",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 20,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "discount"
              }
            ]
          },
          "amount": {
            "value": 900,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "memberliability"
              }
            ]
          },
          "amount": {
            "value": 80,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "paidtoprovider"
              }
            ]
          },
          "amount": {
            "value": 20,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "adjudication": [
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "benefitpaymentstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
            "code": "billingnetworkstatus"
          }
        ]
      },
      "reason": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
            "code": "innetwork"
          }
        ]
      }
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidtoprovider"
          }
        ],
        "text": "Payment Amount"
      },
      "amount": {
        "value": 620,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "version": "1.0.1",
            "code": "submitted"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 2650,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "code": "paidbypatient"
          }
        ],
        "text": "Patient Pay Amount"
      },
      "amount": {
        "value": 0,
        "currency": "USD"
      }
    }
  ]
}