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Source1

{
  "resourceType": "CodeSystem",
  "id": "sbc-benefit-category",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "claims"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "informative",
      "_valueCode": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://hl7.org/fhir/us/insurance-card/ImplementationGuide/hl7.fhir.us.insurance-card"
          }
        ]
      }
    }
  ],
  "url": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
  "version": "2.0.0",
  "name": "SBCBenefitCategoryCS",
  "title": "SBC Benefit Category Code System",
  "status": "draft",
  "experimental": true,
  "date": "2026-02-03T01:43:53+00:00",
  "publisher": "HL7 International / Payer/Provider Information Exchange Work Group",
  "contact": [
    {
      "name": "HL7 International / Payer/Provider Information Exchange Work Group",
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/claims"
        },
        {
          "system": "email",
          "value": "pie@lists.HL7.org"
        }
      ]
    }
  ],
  "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"
    }
  ]
}