| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ExplanationOfBenefit
|
C | C4BBExplanationOfBenefit | EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required. | |
identifier
|
S | |||
|
type
|
Required Pattern: At least the following | |||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: pharmacy |
|
|
created
|
S | |||
|
careTeam
|
C |
EOB-pharm-careTeam-practitioner:
Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization |
||
|
role
|
1.. | Binding: C4BB Claim Pharmacy CareTeam Role Value Set ( required ) | ||
Slices for supportingInfo
|
4 .. | Slice: Unordered, Open by pattern:category | ||
supportingInfo:dayssupply
|
S | 1..1 | Days supply | |
category
|
S | Required Pattern: At least the following | ||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: dayssupply |
|
value[x]
|
S | 1.. | Quantity | |
|
supportingInfo:dawcode
|
S | 1..1 | Dispense and written product selection code | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: dawcode |
|
|
code
|
S | 1.. | Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set ( required ) | |
|
supportingInfo:refillNum
|
S | 1..1 | The number fill of the claim dispensed supply | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: refillnum |
|
|
value[x]
|
S | 1.. | Quantity | |
|
supportingInfo:refillsAuthorized
|
1..1 | Number or refills authorized by prescriber | ||
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: refillsauthorized |
|
|
value[x]
|
S | 1.. | Quantity | |
|
supportingInfo:brandgenericindicator
|
S | 0..1 | Plan reported brand or generic drug indicator | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: brandgenericindicator |
|
|
code
|
S | 1.. | Binding: NCPDP Brand Generic Indicator Value Set ( required ) | |
|
supportingInfo:rxoriginCode
|
S | 0..1 | Prescription origin code | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: rxorigincode |
|
|
code
|
S | 1.. | Binding: NCPDP Prescription Origin Code Value Set ( required ) | |
|
supportingInfo:clmrecvddate
|
S | 0..1 | Claim received date | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: clmrecvddate |
|
timing[x]
|
S | 1.. | date | |
supportingInfo:compoundcode
|
S | 0..1 | Code indicating whether or not the prescription is a compound | |
|
category
|
S | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: compoundcode |
|
|
code
|
S | 1.. | Binding: NCPDP Compound Code Value Set ( required ) | |
|
item
|
||||
|
productOrService
|
S | Binding: NDC or Compound Value Set ( required ) | ||
|
serviced[x]
|
S | 1.. | date | |
|
quantity
|
S | |||
|
Slices for adjudication
|
S | 1 .. | Slice: Unordered, Open by pattern:category | |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
Binding: C4BB Adjudication Category Discriminator Value Set ( extensible ) | |||
|
adjudication:adjudicationamounttype
|
S | 1..* |
Line level adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | 1.. | ||
|
adjudication:rejectreason
|
S | 0..1 | Reason codes used to interpret the Non-Covered Amount (92) | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: rejectreason |
|
|
reason
|
S | 1.. | Binding: NCPDP Reject Code Value Set ( required ) | |
|
detail
|
S | |||
|
productOrService
|
S | Binding: National Drug Code (NDC) Value Set ( required ) | ||
|
quantity
|
S | |||
|
Slices for adjudication
|
S | 1 .. | BackboneElement | Slice: Unordered, Open by pattern:category |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | Binding: C4BB Adjudication Category Discriminator Value Set ( extensible ) | ||
|
adjudication:billingnetworkstatus
|
S | 0..1 | Billing provider networking status | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: billingnetworkstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Provider Network Status Value Set ( required ) | |
|
adjudication:benefitpaymentstatus
|
S | 1..1 | Indicates the in network or out of network payment status of the claim. (142) | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus |
|
|
reason
|
S | 1.. | Binding: C4BB Payer Benefit Payment Status Value Set ( required ) | |
|
Slices for total
|
Slice: Unordered, Open by pattern:category | |||
|
total:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | Binding: C4BB Total Category Discriminator Value Set ( extensible ) | ||
|
amount
|
S | |||
|
total:adjudicationamounttype
|
S | 1..* |
Total adjudication type and amount |
|
|
category
|
Binding: C4BB Adjudication Value Set ( required ) | |||
|
amount
|
S | |||
|
payment
|
||||
|
date
|
S | |||
|
processNote
|
||||
|
text
|
S | |||
|
Documentation for this format
|
||||