C4BBExplanationOfBenefitPharmacyBasis

C4BB ExplanationOfBenefit Pharmacy Basis

activeCARIN Blue Button2.2.0resource45 key elements

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) The basis profile does not have requirements for financial data.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy-Basis
ID
C4BB-ExplanationOfBenefit-Pharmacy-Basis
Type
Base Definition
C4BB-ExplanationOfBenefit
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
identifier
S
created
S
careTeam.role
1+
supportingInfo
1+
:dayssupply1..1
S1+
Days supply
supportingInfo.category
S
supportingInfo.value[x]
Quantity
S1+
:dawcode1..1
S1+
Dispense and written product selection code
supportingInfo.category
S
supportingInfo.code
S1+
:refillNum1..1
S1+
The number fill of the claim dispensed supply
supportingInfo.category
S
supportingInfo.value[x]
Quantity
S1+
supportingInfo.category
S
supportingInfo.value[x]
Quantity
S1+
:brandgenericindicator0..1
S
Plan reported brand or generic drug indicator
supportingInfo.category
S
supportingInfo.code
S1+
:rxoriginCode0..1
S
Prescription origin code
supportingInfo.category
S
supportingInfo.code
S1+
:clmrecvddate0..1
S
Claim received date
supportingInfo.category
S
supportingInfo.timing[x]
date
S1+
:compoundcode0..1
S
Code indicating whether or not the prescription is a compound
supportingInfo.category
S
supportingInfo.code
S1+
item.productOrService
S
item.serviced[x]
date
S1+
item.quantity
S
item.adjudication
S
:rejectreason0..*
S
Reason codes used to interpret the Non-Covered Amount (92)
item.adjudication.reason
S1+
item.detail
S
item.detail.productOrService
S
item.detail.quantity
S
adjudication
BackboneElement
S1+
adjudication.category
S
:billingnetworkstatus0..1
S
Billing provider networking status
adjudication.reason
S1+
:benefitpaymentstatus1..1
S1+
Indicates the in network or out of network payment status of the claim. (142)
adjudication.reason
S1+
total.amount
S
payment.date
S
processNote.text
S