description: This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies.\nThe 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)\nThe basis profile does not have requirements for financial data. package_name: hl7.fhir.us.carin-bb derivation: constraint name: C4BBExplanationOfBenefitPharmacyBasis type: ExplanationOfBenefit elements: processNote: elements: text: {mustSupport: true, index: 61} adjudication: type: BackboneElement mustSupport: true index: 51 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} mustSupport: true index: 52 slicing: rules: open ordered: false description: Slice based on value discriminator: - {path: category, type: value} min: 1 slices: billingnetworkstatus: match: category: coding: - {code: billingnetworkstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: short: Billing provider networking status mustSupport: true index: 53 elements: category: pattern: type: CodeableConcept value: coding: - {code: billingnetworkstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 54 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus'} mustSupport: true index: 55 required: [reason] benefitpaymentstatus: match: category: coding: - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: short: Indicates the in network or out of network payment status of the claim. (142) mustSupport: true _required: true index: 56 elements: category: pattern: type: CodeableConcept value: coding: - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 57 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus'} mustSupport: true index: 58 required: [reason] supportingInfo: array: true min: 4 index: 5 slicing: rules: open ordered: false description: Slice based on $this value discriminator: - {path: category, type: value} min: 4 slices: dayssupply: match: category: coding: - {code: dayssupply, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Days supply mustSupport: true _required: true index: 6 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: dayssupply, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 7 value: mustSupport: true choices: [valueQuantity] index: 9 valueQuantity: {type: Quantity, mustSupport: true, choiceOf: value, index: 10} required: [value, valueQuantity] dawcode: match: category: coding: - {code: dawcode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Dispense and written product selection code mustSupport: true _required: true index: 11 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: dawcode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 12 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPDispensedAsWrittenOrProductSelectionCode'} mustSupport: true index: 13 required: [code] refillNum: match: category: coding: - {code: refillnum, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: The number fill of the claim dispensed supply mustSupport: true _required: true index: 14 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: refillnum, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 15 value: mustSupport: true choices: [valueQuantity] index: 17 valueQuantity: {type: Quantity, mustSupport: true, choiceOf: value, index: 18} required: [value, valueQuantity] refillsAuthorized: match: category: coding: - {code: refillsauthorized, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Number or refills authorized by prescriber _required: true index: 19 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: refillsauthorized, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 20 value: mustSupport: true choices: [valueQuantity] index: 22 valueQuantity: {type: Quantity, mustSupport: true, choiceOf: value, index: 23} required: [value, valueQuantity] brandgenericindicator: match: category: coding: - {code: brandgenericindicator, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Plan reported brand or generic drug indicator mustSupport: true index: 24 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: brandgenericindicator, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 25 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPBrandGenericIndicator'} mustSupport: true index: 26 required: [code] rxoriginCode: match: category: coding: - {code: rxorigincode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Prescription origin code mustSupport: true index: 27 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: rxorigincode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 28 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPPrescriptionOriginCode'} mustSupport: true index: 29 required: [code] clmrecvddate: match: category: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Claim received date mustSupport: true index: 30 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: clmrecvddate, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 31 timing: mustSupport: true choices: [timingDate] index: 33 timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 34} required: [timingDate, timing] compoundcode: match: category: coding: - {code: compoundcode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} schema: short: Code indicating whether or not the prescription is a compound mustSupport: true index: 35 elements: category: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: compoundcode, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType'} index: 36 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPCompoundCode'} mustSupport: true index: 37 required: [code] payment: elements: date: {mustSupport: true, index: 60} item: elements: productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/FDANDCOrCompound'} mustSupport: true index: 38 serviced: mustSupport: true choices: [servicedDate] index: 40 servicedDate: {type: date, mustSupport: true, choiceOf: serviced, index: 41} quantity: {mustSupport: true, index: 42} adjudication: mustSupport: true index: 43 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator'} index: 44 slicing: rules: open ordered: false description: Slice based on value discriminator: - {path: category, type: value} min: null slices: rejectreason: match: category: coding: - {code: rejectreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} schema: short: Reason codes used to interpret the Non-Covered Amount (92) mustSupport: true index: 45 elements: category: pattern: type: CodeableConcept value: coding: - {code: rejectreason, system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator'} index: 46 reason: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/NCPDPRejectCode'} mustSupport: true index: 47 required: [reason] detail: mustSupport: true index: 48 elements: productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/FDANationalDrugCode'} mustSupport: true index: 49 quantity: {mustSupport: true, index: 50} required: [servicedDate, serviced] type: pattern: type: CodeableConcept value: coding: - {code: pharmacy, system: 'http://terminology.hl7.org/CodeSystem/claim-type'} index: 1 created: {mustSupport: true, index: 2} total: elements: amount: {mustSupport: true, index: 59} identifier: {mustSupport: true, index: 0} careTeam: constraint: EOB-pharm-careTeam-practitioner: human: 'Pharmacy EOB: Careteam roles refer to a practitioner' source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy-Basis severity: error expression: |- ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies provider.all(resolve() is Organization) ) EOB-pharm-careTeam-organization: human: 'Pharmacy EOB: Careteam roles refer to an organization' source: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy-Basis severity: error expression: |- ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) ) index: 3 elements: role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimPharmacyTeamRole'} index: 4 required: [role] package_version: 2.1.0 class: profile kind: resource url: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy-Basis base: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit version: 2.1.0 required: [adjudication]