ExplanationOfBenefit explanationofbenefit-C4BB-ExplanationOfBenefit-Pharmacy
This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies. The claims data is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program)
Profile Differential
ExplanationOfBenefit
meta Meta
Metadata about the resource.
profile canonical [0..*]
Profiles this resource claims to conform to.
Constant: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy
identifier Identifier [0..*]
Business Identifier for the resource
system* uri
The namespace for the identifier value
value* string
The value that is unique
type CodeableConcept
Description of identifier identifier-type Extensible
status* code
A code specifying the state of the resource instance. explanationofbenefit-status Extensible
type* CodeableConcept
use* code
B
supportingInfo* BackboneElement [3..*]
Supporting information.
p
sequence* positiveInt
Information instance identifier.
category* CodeableConcept
Classification of the supplied information. c4bb-supportinginfo-type Extensible
code CodeableConcept
Type of information.
timing
When it occurred.
date date
Period Period
value
Data to be provided.
boolean boolean
string string
Quantity Quantity
Attachment Attachment
patient* Reference(C4BB Patient)
The recipient of the products and services
created* dateTime
Response creation date
insurer* Reference(C4BB Organization)
Party responsible for reimbursement
provider* Reference(C4BB Organization)
Party responsible for the claim
prescription Reference(MedicationRequest | VisionPrescription)
Prescription authorizing services or products
outcome* code
The result of the claim processing. remittance-outcome Extensible
B
careTeam BackboneElement [0..*]
Care Team members.
p
sequence* positiveInt
Order of care team.
provider* Reference(C4BB Organization | C4BB Practitioner)
Practitioner or organization.
role* CodeableConcept
Function within the team. claim-pharmacy-careteam-role Extensible
B
insurance* BackboneElement [0..*]
Patient insurance information.
focal* boolean
Coverage to be used for adjudication.
Constant: true
coverage* Reference(C4BB Coverage)
Insurance information.
B
item BackboneElement [0..*]
Supporting information.
p
sequence* positiveInt
Item instance identifier.
serviced
Date or dates of service or product delivery.
date date
Period Period
productOrService* CodeableConcept
Billing ndc-or-compound Extensible
B
adjudication BackboneElement [0..*]
Adjudication details.
category* CodeableConcept
Type of adjudication information c4bb-adjudication-category-discriminator Extensible
amount Money
Monetary amount
B
total* BackboneElement [2..*]
Pertinent diagnosis information.
category* CodeableConcept
Type of adjudication information. c4bb-total-category-discriminator Extensible
amount* Money
Financial total for the category.
Snapshot
ExplanationOfBenefit
id id
Logical id of this artifact
meta Meta
Metadata about the resource.
profile canonical [0..*]
Profiles this resource claims to conform to.
Constant: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy
language code
Language of the resource content
text Narrative
Text summary of the resource, for human interpretation
identifier Identifier [0..*]
Business Identifier for the resource
system* uri
The namespace for the identifier value
value* string
The value that is unique
type CodeableConcept
Description of identifier identifier-type Extensible
status* code
A code specifying the state of the resource instance. explanationofbenefit-status required
type* CodeableConcept
subType CodeableConcept
More granular claim type
use* code
patient* Reference(C4BB Patient)
The recipient of the products and services
billablePeriod Period
Relevant time frame for the claim
created* dateTime
Response creation date
enterer Reference
Author of the claim
insurer* Reference(C4BB Organization)
Party responsible for reimbursement
provider* Reference(C4BB Organization)
Party responsible for the claim
priority CodeableConcept
Desired processing urgency
fundsReserveRequested CodeableConcept
For whom to reserve funds
fundsReserve CodeableConcept
Funds reserved status
related [0..*]
Prior or corollary claims
id string
Unique id for inter-element referencing
claim Reference
Reference to the related claim
relationship CodeableConcept
How the reference claim is related
reference Identifier
File or case reference
prescription Reference(MedicationRequest | VisionPrescription)
Prescription authorizing services or products
originalPrescription Reference
Original prescription if superceded by fulfiller
payee
Recipient of benefits payable
id string
Unique id for inter-element referencing
type CodeableConcept
Category of recipient
party Reference
Recipient reference
referral Reference
Treatment Referral
facility Reference
Servicing Facility
claim Reference
Claim reference
claimResponse Reference
Claim response reference
outcome* code
The result of the claim processing. remittance-outcome required
disposition string
Disposition Message
preAuthRef string [0..*]
Preauthorization reference
preAuthRefPeriod Period [0..*]
Preauthorization in-effect period
B
careTeam BackboneElement [0..*]
Care Team members.
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Order of care team.
provider* Reference(C4BB Organization | C4BB Practitioner)
Practitioner or organization.
responsible boolean
Indicator of the lead practitioner
role* CodeableConcept
Function within the team. claim-pharmacy-careteam-role Extensible
qualification CodeableConcept
Practitioner credential or specialization
B
supportingInfo* BackboneElement [3..*]
Supporting information.
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Information instance identifier.
category* CodeableConcept
Classification of the supplied information. c4bb-supportinginfo-type Extensible
code CodeableConcept
Type of information.
timing
When it occurred.
date date
Period Period
value
Data to be provided.
boolean boolean
string string
Quantity Quantity
Attachment Attachment
reason Coding
Explanation for the information
diagnosis [0..*]
Pertinent diagnosis information
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Diagnosis instance identifier
diagnosis*
Nature of illness or problem
CodeableConcept CodeableConcept
Reference Reference
type CodeableConcept [0..*]
Timing or nature of the diagnosis
onAdmission CodeableConcept
Present on admission
packageCode CodeableConcept
Package billing code
procedure [0..*]
Clinical procedures performed
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Procedure instance identifier
type CodeableConcept [0..*]
Category of Procedure
date dateTime
When the procedure was performed
procedure*
Specific clinical procedure
CodeableConcept CodeableConcept
Reference Reference
udi Reference [0..*]
Unique device identifier
p
precedence positiveInt
Precedence (primary, secondary, etc.)
B
insurance* BackboneElement [0..*]
Patient insurance information.
id string
Unique id for inter-element referencing
focal* boolean
Coverage to be used for adjudication.
Constant: true
coverage* Reference(C4BB Coverage)
Insurance information.
preAuthRef string [0..*]
Prior authorization reference number
accident
Details of the event
id string
Unique id for inter-element referencing
date date
When the incident occurred
type CodeableConcept
The nature of the accident
location
Where the event occurred
Address Address
Reference Reference
B
item BackboneElement [0..*]
Supporting information.
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Item instance identifier.
p
careTeamSequence positiveInt [0..*]
Applicable care team members
p
diagnosisSequence positiveInt [0..*]
Applicable diagnoses
p
procedureSequence positiveInt [0..*]
Applicable procedures
p
informationSequence positiveInt [0..*]
Applicable exception and supporting information
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing ndc-or-compound Extensible
modifier CodeableConcept [0..*]
Product or service billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
serviced
Date or dates of service or product delivery.
date date
Period Period
location
Place of service or where product was supplied
CodeableConcept CodeableConcept
Address Address
Reference Reference
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
bodySite CodeableConcept
Anatomical location
subSite CodeableConcept [0..*]
Anatomical sub-location
encounter Reference [0..*]
Encounters related to this billed item
p
noteNumber positiveInt [0..*]
Applicable note numbers
B
adjudication BackboneElement [0..*]
Adjudication details.
id string
Unique id for inter-element referencing
category* CodeableConcept
Type of adjudication information c4bb-adjudication-category-discriminator Extensible
reason CodeableConcept
Explanation of adjudication outcome
amount Money
Monetary amount
d
value decimal
Non-monitary value
detail [0..*]
Additional items
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Product or service provided
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Detail level adjudication details
subDetail [0..*]
Additional items
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Product or service provided
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Subdetail level adjudication details
addItem [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
p
itemSequence positiveInt [0..*]
Item sequence number
p
detailSequence positiveInt [0..*]
Detail sequence number
p
subDetailSequence positiveInt [0..*]
Subdetail sequence number
provider Reference [0..*]
Authorized providers
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
serviced
Date or dates of service or product delivery
date date
Period Period
location
Place of service or where product was supplied
CodeableConcept CodeableConcept
Address Address
Reference Reference
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
bodySite CodeableConcept
Anatomical location
subSite CodeableConcept [0..*]
Anatomical sub-location
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
detail [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
subDetail [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
?
adjudication [0..*]
Header-level adjudication
B
total* BackboneElement [2..*]
Pertinent diagnosis information.
id string
Unique id for inter-element referencing
category* CodeableConcept
Type of adjudication information. c4bb-total-category-discriminator Extensible
amount* Money
Financial total for the category.
payment
Payment Details
id string
Unique id for inter-element referencing
type CodeableConcept
Partial or complete payment
adjustment Money
Payment adjustment for non-claim issues
adjustmentReason CodeableConcept
Explanation for the variance
date date
Expected date of payment
amount Money
Payable amount after adjustment
identifier Identifier
Business identifier for the payment
formCode CodeableConcept
Printed form identifier
form Attachment
Printed reference or actual form
processNote [0..*]
Note concerning adjudication
id string
Unique id for inter-element referencing
p
number positiveInt
Note instance identifier
type code
display | print | printoper note-type required
text string
Note explanatory text
language CodeableConcept
Language of the text
benefitPeriod Period
When the benefits are applicable
benefitBalance [0..*]
Balance by Benefit Category
id string
Unique id for inter-element referencing
category* CodeableConcept
Benefit classification
excluded boolean
Excluded from the plan
name string
Short name for the benefit
description string
Description of the benefit or services covered
network CodeableConcept
In or out of network
unit CodeableConcept
Individual or family
term CodeableConcept
Annual or lifetime
financial [0..*]
Benefit Summary
id string
Unique id for inter-element referencing
type* CodeableConcept
Benefit classification
allowed
Benefits allowed
u
unsignedInt unsignedInt
string string
Money Money
used
Benefits used
u
unsignedInt unsignedInt
Money Money
Examples
Resource Content
This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
ExplanationOfBenefit
id id
Logical id of this artifact
meta Meta
Metadata about the resource
language code
Language of the resource content
text Narrative
Text summary of the resource, for human interpretation
identifier Identifier [0..*]
Business Identifier for the resource
status* code
active | cancelled | draft | entered-in-error explanationofbenefit-status required
type* CodeableConcept
Category or discipline
subType CodeableConcept
More granular claim type
use* code
claim | preauthorization | predetermination claim-use required
patient* Reference
The recipient of the products and services
billablePeriod Period
Relevant time frame for the claim
created* dateTime
Response creation date
enterer Reference
Author of the claim
insurer* Reference
Party responsible for reimbursement
provider* Reference
Party responsible for the claim
priority CodeableConcept
Desired processing urgency
fundsReserveRequested CodeableConcept
For whom to reserve funds
fundsReserve CodeableConcept
Funds reserved status
related [0..*]
Prior or corollary claims
id string
Unique id for inter-element referencing
claim Reference
Reference to the related claim
relationship CodeableConcept
How the reference claim is related
reference Identifier
File or case reference
prescription Reference
Prescription authorizing services or products
originalPrescription Reference
Original prescription if superceded by fulfiller
payee
Recipient of benefits payable
id string
Unique id for inter-element referencing
type CodeableConcept
Category of recipient
party Reference
Recipient reference
referral Reference
Treatment Referral
facility Reference
Servicing Facility
claim Reference
Claim reference
claimResponse Reference
Claim response reference
outcome* code
queued | complete | error | partial remittance-outcome required
disposition string
Disposition Message
preAuthRef string [0..*]
Preauthorization reference
preAuthRefPeriod Period [0..*]
Preauthorization in-effect period
careTeam [0..*]
Care Team members
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Order of care team
provider* Reference
Practitioner or organization
responsible boolean
Indicator of the lead practitioner
role CodeableConcept
Function within the team
qualification CodeableConcept
Practitioner credential or specialization
supportingInfo [0..*]
Supporting information
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Information instance identifier
category* CodeableConcept
Classification of the supplied information
code CodeableConcept
Type of information
timing
When it occurred
date date
Period Period
value
Data to be provided
boolean boolean
string string
Quantity Quantity
Attachment Attachment
Reference Reference
reason Coding
Explanation for the information
diagnosis [0..*]
Pertinent diagnosis information
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Diagnosis instance identifier
diagnosis*
Nature of illness or problem
CodeableConcept CodeableConcept
Reference Reference
type CodeableConcept [0..*]
Timing or nature of the diagnosis
onAdmission CodeableConcept
Present on admission
packageCode CodeableConcept
Package billing code
procedure [0..*]
Clinical procedures performed
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Procedure instance identifier
type CodeableConcept [0..*]
Category of Procedure
date dateTime
When the procedure was performed
procedure*
Specific clinical procedure
CodeableConcept CodeableConcept
Reference Reference
udi Reference [0..*]
Unique device identifier
p
precedence positiveInt
Precedence (primary, secondary, etc.)
insurance* [0..*]
Patient insurance information
id string
Unique id for inter-element referencing
focal* boolean
Coverage to be used for adjudication
coverage* Reference
Insurance information
preAuthRef string [0..*]
Prior authorization reference number
accident
Details of the event
id string
Unique id for inter-element referencing
date date
When the incident occurred
type CodeableConcept
The nature of the accident
location
Where the event occurred
Address Address
Reference Reference
item [0..*]
Product or service provided
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Item instance identifier
p
careTeamSequence positiveInt [0..*]
Applicable care team members
p
diagnosisSequence positiveInt [0..*]
Applicable diagnoses
p
procedureSequence positiveInt [0..*]
Applicable procedures
p
informationSequence positiveInt [0..*]
Applicable exception and supporting information
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Product or service billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
serviced
Date or dates of service or product delivery
date date
Period Period
location
Place of service or where product was supplied
CodeableConcept CodeableConcept
Address Address
Reference Reference
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
bodySite CodeableConcept
Anatomical location
subSite CodeableConcept [0..*]
Anatomical sub-location
encounter Reference [0..*]
Encounters related to this billed item
p
noteNumber positiveInt [0..*]
Applicable note numbers
adjudication [0..*]
Adjudication details
id string
Unique id for inter-element referencing
category* CodeableConcept
Type of adjudication information
reason CodeableConcept
Explanation of adjudication outcome
amount Money
Monetary amount
d
value decimal
Non-monitary value
detail [0..*]
Additional items
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Product or service provided
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Detail level adjudication details
subDetail [0..*]
Additional items
id string
Unique id for inter-element referencing
p
sequence* positiveInt
Product or service provided
revenue CodeableConcept
Revenue or cost center code
category CodeableConcept
Benefit classification
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
udi Reference [0..*]
Unique device identifier
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Subdetail level adjudication details
addItem [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
p
itemSequence positiveInt [0..*]
Item sequence number
p
detailSequence positiveInt [0..*]
Detail sequence number
p
subDetailSequence positiveInt [0..*]
Subdetail sequence number
provider Reference [0..*]
Authorized providers
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
programCode CodeableConcept [0..*]
Program the product or service is provided under
serviced
Date or dates of service or product delivery
date date
Period Period
location
Place of service or where product was supplied
CodeableConcept CodeableConcept
Address Address
Reference Reference
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
bodySite CodeableConcept
Anatomical location
subSite CodeableConcept [0..*]
Anatomical sub-location
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
detail [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
subDetail [0..*]
Insurer added line items
id string
Unique id for inter-element referencing
productOrService* CodeableConcept
Billing, service, product, or drug code
modifier CodeableConcept [0..*]
Service/Product billing modifiers
quantity Quantity
Count of products or services
unitPrice Money
Fee, charge or cost per item
d
factor decimal
Price scaling factor
net Money
Total item cost
p
noteNumber positiveInt [0..*]
Applicable note numbers
?
adjudication [0..*]
Added items adjudication
?
adjudication [0..*]
Header-level adjudication
total [0..*]
Adjudication totals
id string
Unique id for inter-element referencing
category* CodeableConcept
Type of adjudication information
amount* Money
Financial total for the category
payment
Payment Details
id string
Unique id for inter-element referencing
type CodeableConcept
Partial or complete payment
adjustment Money
Payment adjustment for non-claim issues
adjustmentReason CodeableConcept
Explanation for the variance
date date
Expected date of payment
amount Money
Payable amount after adjustment
identifier Identifier
Business identifier for the payment
formCode CodeableConcept
Printed form identifier
form Attachment
Printed reference or actual form
processNote [0..*]
Note concerning adjudication
id string
Unique id for inter-element referencing
p
number positiveInt
Note instance identifier
type code
display | print | printoper note-type required
text string
Note explanatory text
language CodeableConcept
Language of the text
benefitPeriod Period
When the benefits are applicable
benefitBalance [0..*]
Balance by Benefit Category
id string
Unique id for inter-element referencing
category* CodeableConcept
Benefit classification
excluded boolean
Excluded from the plan
name string
Short name for the benefit
description string
Description of the benefit or services covered
network CodeableConcept
In or out of network
unit CodeableConcept
Individual or family
term CodeableConcept
Annual or lifetime
financial [0..*]
Benefit Summary
id string
Unique id for inter-element referencing
type* CodeableConcept
Benefit classification
allowed
Benefits allowed
u
unsignedInt unsignedInt
string string
Money Money
used
Benefits used
u
unsignedInt unsignedInt
Money Money