Corner Pharmacy #204

claim eob-rx-11 · 1 line

Line 1

Claim ID: eob-rx-11
Provider: Corner Pharmacy #204
Service date: 2025-11-26
Claim type: pharmacy
Code system: ndc
Service code: 59762-1740-01
Service: Sertraline 50mg, 30 tablets (generic)
Billed: $29.18
Allowed: $29.18
Plan paid: $19.18
Deductible: $0.00
Copay: $10.00
Coinsurance: $0.00
Noncovered: $0.00
Your share: $10.00
Adjudication: paid
Denial code: not set
Denial reason: not set
Prior auth reference: not set

Raw FHIR ExplanationOfBenefit

{
  "resourceType": "ExplanationOfBenefit",
  "id": "eob-rx-11",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "pharmacy"
      }
    ],
    "text": "pharmacy"
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-1"
  },
  "billablePeriod": {
    "start": "2025-11-26",
    "end": "2025-11-26"
  },
  "created": "2025-11-26",
  "insurer": {
    "display": "Acme Health Plan"
  },
  "provider": {
    "display": "Corner Pharmacy #204"
  },
  "outcome": "complete",
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "productOrService": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/ndc",
            "code": "59762-1740-01",
            "display": "Sertraline 50mg, 30 tablets (generic)"
          }
        ]
      },
      "servicedDate": "2025-11-26",
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 29.18,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 19.18,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "deductible"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "coinsurance"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
                "code": "noncovered"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 29.18,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 19.18,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "amount": {
      "value": 19.18,
      "currency": "USD"
    }
  }
}