ExplanationOfBenefit-Pharmacy.json

{
    "resourceType": "StructureDefinition",
    "id": "ExplanationOfBenefit-Pharmacy",
    "url": "https://bfd.cms.gov/fhir/StructureDefinition/ExplanationOfBenefit-Pharmacy",
    "name": "ExplanationOfBenefit-Pharmacy",
    "status": "draft",
    "fhirVersion": "4.0.1",
    "kind": "logical",
    "abstract": true,
    "type": "ExplanationOfBenefit-Pharmacy",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Base",
    "derivation": "specialization",
    "differential": {
        "element": [
            {
                "id": "ExplanationOfBenefit-Pharmacy",
                "path": "ExplanationOfBenefit-Pharmacy",
                "label": "Explanation of Benefit Pharmacy Resource for IDR. Ignore in DD Generation",
                "min": 1,
                "max": "1"
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.lastUpdated",
                "path": "ExplanationOfBenefit-Pharmacy.lastUpdated",
                "label": "Last Updated Time",
                "definition": "This field represents the last time that an ExplanationOfBenefit was updated.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_BENE_XREF_EFCTV_SK",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_BENE_XREF_EFCTV_SK",
                "label": "Beneficiary Source Key",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.BENE_SK",
                "path": "ExplanationOfBenefit-Pharmacy.BENE_SK",
                "label": "Beneficiary Source Key - On Claim",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_TYPE_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_TYPE_CD",
                "label": "Claim Type Code",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "integer"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_UNIQ_ID",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_UNIQ_ID",
                "label": "Claim Unique ID",
                "definition": "The claim unique ID is a unique ID for the claim within the source system.",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_CNTL_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_CNTL_NUM",
                "label": "Claim Control Number",
                "definition": "This field is an identification value assigned by a MAC. It provides a reference number for the control and monitoring of specific claims, and to differentiate between claims for the beneficiary.",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_ORIG_CNTL_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_ORIG_CNTL_NUM",
                "label": "Original Claim Control Number",
                "definition": "This field contains the original claim control number for adjusted or corrected claims. It provides a reference to the prior claim that this claim is adjusting or correcting.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_FROM_DT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_FROM_DT",
                "label": "Claim From Date",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_THRU_DT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_THRU_DT",
                "label": "Claim Thru Date",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_EFCTV_DT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_EFCTV_DT",
                "label": "Claim Effective Date",
                "definition": "The effective date of the claim",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SRC_ID",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SRC_ID",
                "label": "Claim Source ID",
                "min": 1,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SRVC_PRVDR_GNRC_ID_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SRVC_PRVDR_GNRC_ID_NUM",
                "label": "Service Provider Generic ID Number",
                "definition": "The generic ID number of the service provider.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.clm_srvc_prvdr_gnrc_id_type",
                "path": "ExplanationOfBenefit-Pharmacy.clm_srvc_prvdr_gnrc_id_type",
                "label": "Service Provider Generic ID Type",
                "definition": "The type of service provider (1 for practitioner, 2 for organization).",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_PD_DT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_PD_DT",
                "label": "Payment Date",
                "definition": "The date on which the plan originally paid the pharmacy for the prescription drug.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_CMS_PROC_DT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_CMS_PROC_DT",
                "label": "CMS Process Date",
                "definition": "The date when CMS processed the claim.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "date"
                    }
                ]
            },

            {
                "id": "ExplanationOfBenefit-Pharmacy.PRVDR_PRSCRBNG_PRVDR_NPI_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.PRVDR_PRSCRBNG_PRVDR_NPI_NUM",
                "label": "Prescribing Provider NPI Number",
                "definition": "The NPI number of the prescribing provider.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.PRVDR_PRSCRBNG_PRVDR_NPI_TYPE",
                "path": "ExplanationOfBenefit-Pharmacy.PRVDR_PRSCRBNG_PRVDR_NPI_TYPE",
                "label": "Prescribing Provider NPI Type",
                "definition": "The type of prescribing provider (1 for practitioner, 2 for organization).",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_PHRMCY_SRVC_TYPE_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_PHRMCY_SRVC_TYPE_CD",
                "label": "Pharmacy Service Type Code",
                "definition": "The type of pharmacy used. This variable indicates the type of pharmacy that dispensed the prescription.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_RX_ORGN_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_RX_ORGN_CD",
                "label": "Prescription Origin Code",
                "definition": "This variable indicates whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_BRND_GNRC_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_BRND_GNRC_CD",
                "label": "Brand Generic Code",
                "definition": "Plan reported value indicating whether the plan adjudicated the claim as a brand or generic drug.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_PTNT_RSDNC_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_PTNT_RSDNC_CD",
                "label": "Patient Residence Code",
                "definition": "This variable indicates where the beneficiary lived when the prescription was filled, as reported on the PDE record.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LTC_DSPNSNG_MTHD_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LTC_DSPNSNG_MTHD_CD",
                "label": "Submission Clarification Code",
                "definition": "For beneficiaries living in long-term care (LTC) facilities, this variable indicates how many days' supply of the medication was dispensed by the long-term care pharmacy.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_CMPND_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_CMPND_CD",
                "label": "Compound Code",
                "definition": "This field indicates whether or not the dispensed drug was compounded or mixed.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_DAYS_SUPLY_QTY",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_DAYS_SUPLY_QTY",
                "label": "Days Supply",
                "definition": "This field indicates the number of days' supply of medication dispensed by the pharmacy and consists of the amount the pharmacy enters for the prescription.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_RX_FILL_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_RX_FILL_NUM",
                "label": "Fill Number",
                "definition": "This field indicates the number fill of the current dispensed supply.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_DAW_PROD_SLCTN_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_DAW_PROD_SLCTN_CD",
                "label": "Dispense as Written Product Selection Code",
                "definition": "This field indicates the prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_DRUG_CVRG_STUS_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_DRUG_CVRG_STUS_CD",
                "label": "Drug Coverage Status Code",
                "definition": "This field indicates whether or not the drug is covered by Medicare Part D.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_CTSTRPHC_CVRG_IND_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_CTSTRPHC_CVRG_IND_CD",
                "label": "Catastrophic Coverage Code",
                "definition": "This variable indicates whether the PDE occurred within the catastrophic benefit phase of the Medicare Part D benefit.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_CD",
                "label": "National Drug Code",
                "definition": "This field identifies the dispensed drug product using a National Drug Code (NDC).",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_QTY",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_QTY",
                "label": "Quantity Dispensed",
                "definition": "This field indicates the number of units, grams, milliliters, or other quantity dispensed in the current drug event.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_QTY_QLFYR_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NDC_QTY_QLFYR_CD",
                "label": "Quantity Qualifier Code",
                "definition": "The qualifier code for the quantity dispensed.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_CVRD_PD_AMT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_CVRD_PD_AMT",
                "label": "Covered Paid Amount",
                "definition": "This is the net amount that the Part D plan paid for a PDE that was covered by the Medicare Part D benefit.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NCVRD_CHRG_AMT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NCVRD_CHRG_AMT",
                "label": "Noncovered Charge Amount",
                "definition": "The amount that was not covered by the plan.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_LINE_NUM",
                "label": "Line Number",
                "definition": "The line number for this item.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SBMT_CHRG_AMT",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SBMT_CHRG_AMT",
                "label": "Submitted Charge Amount",
                "definition": "The total amount submitted for the claim.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SBMTR_CNTRCT_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SBMTR_CNTRCT_NUM",
                "label": "Submitter Contract Number",
                "definition": "The contract number of the submitter.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SBMTR_CNTRCT_PBP_NUM",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SBMTR_CNTRCT_PBP_NUM",
                "label": "Submitter Contract PBP Number",
                "definition": "The PBP number of the submitter contract.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CNTRCT_PBP_NAME",
                "path": "ExplanationOfBenefit-Pharmacy.CNTRCT_PBP_NAME",
                "label": "Contract PBP Name",
                "definition": "This field contains the name of the plan benefit package (PBP) for the beneficiary's Part D plan of record for the year.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.CLM_SBMT_FRMT_CD",
                "path": "ExplanationOfBenefit-Pharmacy.CLM_SBMT_FRMT_CD",
                "label": "Claim Submission Format Code",
                "definition": "A code indicating the method or format used to submit the claim.",
                "min": 0,
                "max": "1",
                "type": [
                    {
                        "code": "string"
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.supportingInfoComponents",
                "path": "ExplanationOfBenefit-Pharmacy.supportingInfoComponents",
                "label": "Supporting Info Components",
                "definition": "A list of supporting info",
                "min": 0,
                "max": "*",
                "type": [
                    {
                        "code": "SupportingInfoComponent",
                        "targetProfile": [
                            "https://bfd.cms.gov/fhir/StructureDefinition/SupportingInfoComponent"
                        ]
                    }
                ]
            },
            {
                "id": "ExplanationOfBenefit-Pharmacy.lineItemComponents",
                "path": "ExplanationOfBenefit-Pharmacy.lineItemComponents",
                "label": "Line Item Components",
                "definition": "A list of line items",
                "min": 0,
                "max": "*",
                "type": [
                    {
                        "code": "LineItemComponent",
                        "targetProfile": [
                            "https://bfd.cms.gov/fhir/StructureDefinition/LineItemComponent"
                        ]
                    }
                ]
            }
        ]
    }
}