LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
{
"resourceType" : "ExplanationOfBenefit",
"id" : "CDMExplanationOfBenefitForAnalyticsDrugInstance",
"meta" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id",
"valueString" : "tenant7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id",
"valueString" : "rgVCJnQBxvghkKTI8Hzzx2"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name",
"valueString" : "TREX"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id",
"valueString" : "7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id",
"valueIdentifier" : {
"system" : "http://acme-health.com/WellnessCenterPharmacy",
"value" : "7209_07869_e00080779_3938586_2516181_x2"
}
}
],
"source" : "http://acme-health.com/WellnessCenterPharmacy",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-explanation-of-benefit-for-analytics"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"CDMExplanationOfBenefitForAnalyticsDrugInstance\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ExplanationOfBenefit \"CDMExplanationOfBenefitForAnalyticsDrugInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessCenterPharmacy!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-explanation-of-benefit-for-analytics.html\">CDM Explanation of Benefit for Analytics</a></p></div><p><b>Snapshot Age In Years</b>: 27</p><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078x2(use: OFFICIAL)</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy; Pharmacy claims for goods and services <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-claim-type.html\">Payer Claim Type Codes</a>#pharmacy; local-claim-type#Pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-CDMPatientInstance.html\">Patient/CDMPatientInstance</a> \" MCLASTNAME\"</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>insurer</b>: <span></span></p><p><b>provider</b>: <a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>outcome</b>: complete</p><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</td><td>Ordering provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#ordering)</span></td></tr></table><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Day Supply <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-category.html\">Claim Supporting Info Category Codes</a>#dayssupply)</span></p><p><b>value</b>: 28</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: 0 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ncpdp-dispense-as-written.html\">NCPDP Dispense As Written Codes</a>#0)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Refill number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#refill-number)</span></p><p><b>value</b>: 1</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Retail <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-rx-mail-or-retail.html\">Rx Mail Or Retail Codes</a>#r)</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"Coverage-PrimaryPayerExample.html\">Coverage/PrimaryPayerExample</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Capitated Service Indicator</b>: N</p><p><b>Average Wholesale Price</b>: <span title=\"US Dollar\">US$2.88</span> (USD)</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><p><b>serviced</b>: 2017-06-18</p><p><b>location</b>: Pharmacy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#01; local-place-of-service#LocalPlcOfService)</span></p><p><b>quantity</b>: 4 metric</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#coinsurance)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0.48</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Copayment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#copay)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Deductible Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#deductible)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Third Party Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#third-party)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Allowed Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#allowed)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1.59</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Net Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#net-payment)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1.11</td><td>USD</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Dispensing Fee <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#dispensing-fee)</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0.45</td><td>USD</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Ingredient Cost <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#ingredient-cost)</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1.14</td><td>USD</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Sales Tax <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#sales-tax)</span></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td></tr><tr><td>*</td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-paid-in-network-indicator.html\">Paid In Network Indicator Codes</a>#in-network)</span></td></tr></table></div>"
},
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years",
"valueUnsignedInt" : 27
}
],
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "SSRI"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-eob-identifier",
"value" : "000000000000000000019721078x2",
"assigner" : {
"display" : "Acme Health - Wellness Center Pharmacy"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type",
"code" : "pharmacy"
},
{
"system" : "http://acme-health.com/CodeSystem/local-claim-type",
"code" : "Pharmacy"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/CDMPatientInstance"
},
"created" : "2017-07-25T17:31:00-05:00",
"insurer" : {
"type" : "Organization",
"identifier" : {
"system" : "http://acme-health.com/payer1/payer",
"value" : "Payer1"
}
},
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"outcome" : "complete",
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "ordering"
}
]
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-category",
"code" : "dayssupply"
}
]
},
"valueQuantity" : {
"value" : 28
}
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ncpdp-dispense-as-written",
"code" : "0",
"display" : "0"
}
]
}
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "refill-number"
}
]
},
"valueQuantity" : {
"value" : 1
}
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/rx-mail-or-retail",
"code" : "r"
}
]
}
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/PrimaryPayerExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/average-wholesale-price",
"valueMoney" : {
"value" : 2.88,
"currency" : "USD"
}
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"servicedDate" : "2017-06-18",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "01",
"display" : "Pharmacy"
},
{
"system" : "http://acme-health.com/CodeSystem/local-place-of-service",
"code" : "LocalPlcOfService"
}
]
},
"quantity" : {
"value" : 4,
"unit" : "metric"
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "coinsurance"
}
]
},
"amount" : {
"value" : 0.48,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "copay"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "deductible"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "third-party"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "allowed"
}
]
},
"amount" : {
"value" : 1.59,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "net-payment"
}
]
},
"amount" : {
"value" : 1.11,
"currency" : "USD"
}
}
],
"detail" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "dispensing-fee"
}
]
}
}
],
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 0.45,
"currency" : "USD"
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "ingredient-cost"
}
]
}
}
],
"sequence" : 2,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 1.14,
"currency" : "USD"
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "sales-tax"
}
]
}
}
],
"sequence" : 3,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 0,
"currency" : "USD"
}
}
]
}
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator",
"code" : "in-network"
}
]
}
}
]
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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