LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="CDMExplanationOfBenefitForAnalyticsDrugInstance"/>
<meta>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id">
<valueString value="tenant7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzzx2"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id">
<valueString value="7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessCenterPharmacy"/>
<value value="7209_07869_e00080779_3938586_2516181_x2"/>
</valueIdentifier>
</extension>
<source value="http://acme-health.com/WellnessCenterPharmacy"/>
<profile
value="http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-explanation-of-benefit-for-analytics"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years">
<valueUnsignedInt value="27"/>
</extension>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-eob-identifier"/>
<value value="000000000000000000019721078x2"/>
<assigner>
<display value="Acme Health - Wellness Center Pharmacy"/>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type"/>
<code value="pharmacy"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="Pharmacy"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<created value="2017-07-25T17:31:00-05:00"/>
<insurer>
<type value="Organization"/>
<identifier>
<system value="http://acme-health.com/payer1/payer"/>
<value value="Payer1"/>
</identifier>
</insurer>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<outcome value="complete"/>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="ordering"/>
</coding>
</role>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-category"/>
<code value="dayssupply"/>
</coding>
</category>
<valueQuantity>
<value value="28"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ncpdp-dispense-as-written"/>
<code value="0"/>
<display value="0"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="refill-number"/>
</coding>
</code>
<valueQuantity>
<value value="1"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/rx-mail-or-retail"/>
<code value="r"/>
</coding>
</code>
</supportingInfo>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/PrimaryPayerExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/average-wholesale-price">
<valueMoney>
<value value="2.88"/>
<currency value="USD"/>
</valueMoney>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<servicedDate value="2017-06-18"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="01"/>
<display value="Pharmacy"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-place-of-service"/>
<code value="LocalPlcOfService"/>
</coding>
</locationCodeableConcept>
<quantity>
<value value="4"/>
<unit value="metric"/>
</quantity>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="coinsurance"/>
</coding>
</category>
<amount>
<value value="0.48"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="deductible"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="third-party"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="allowed"/>
</coding>
</category>
<amount>
<value value="1.59"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="net-payment"/>
</coding>
</category>
<amount>
<value value="1.11"/>
<currency value="USD"/>
</amount>
</adjudication>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="dispensing-fee"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="1"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="0.45"/>
<currency value="USD"/>
</unitPrice>
</detail>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="ingredient-cost"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="2"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="1.14"/>
<currency value="USD"/>
</unitPrice>
</detail>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="sales-tax"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="3"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="0"/>
<currency value="USD"/>
</unitPrice>
</detail>
</item>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator"/>
<code value="in-network"/>
</coding>
</category>
</adjudication>
</ExplanationOfBenefit>
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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