AmeriHealth Caritas · Schema

AmeriHealthCaritasExplanationOfBenefit

JSON Schema mirroring the FHIR R4 ExplanationOfBenefit resource as profiled by CARIN Blue Button and exposed via AmeriHealth Caritas Patient Access. EOB describes claim adjudication results for AmeriHealth Caritas Medicaid, CHIP, D-SNP, LTSS, and Marketplace members.

HealthcareHealth InsuranceManaged CareMedicaidMedicareDual EligibleCHIPLTSSBehavioral HealthPharmacy BenefitsInteroperabilityFHIRCMSSMART On FHIRPatient AccessProvider Directory

Properties

Name Type Description
resourceType string
id string
meta object
identifier array
status string
type object
subType object
use string
patient object Reference(Patient)
billablePeriod object
created string
insurer object Reference(Organization)
provider object Reference(Practitioner|PractitionerRole|Organization)
outcome string
disposition string
insurance array
item array
total array
payment object
View JSON Schema on GitHub

JSON Schema

amerihealth-caritas-explanation-of-benefit-schema.json Raw ↑ 
{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://raw.githubusercontent.com/api-evangelist/amerihealth-caritas/refs/heads/main/json-schema/amerihealth-caritas-explanation-of-benefit-schema.json",
  "title": "AmeriHealthCaritasExplanationOfBenefit",
  "description": "JSON Schema mirroring the FHIR R4 ExplanationOfBenefit resource as profiled by CARIN Blue Button and exposed via AmeriHealth Caritas Patient Access. EOB describes claim adjudication results for AmeriHealth Caritas Medicaid, CHIP, D-SNP, LTSS, and Marketplace members.",
  "type": "object",
  "required": ["resourceType", "status", "type", "use", "patient", "created", "insurer", "provider", "outcome"],
  "properties": {
    "resourceType": { "type": "string", "const": "ExplanationOfBenefit" },
    "id": { "type": "string" },
    "meta": { "type": "object" },
    "identifier": { "type": "array", "items": { "type": "object" } },
    "status": { "type": "string", "enum": ["active", "cancelled", "draft", "entered-in-error"] },
    "type": { "type": "object" },
    "subType": { "type": "object" },
    "use": { "type": "string", "enum": ["claim", "preauthorization", "predetermination"] },
    "patient": { "type": "object", "description": "Reference(Patient)" },
    "billablePeriod": {
      "type": "object",
      "properties": {
        "start": { "type": "string", "format": "date" },
        "end": { "type": "string", "format": "date" }
      }
    },
    "created": { "type": "string", "format": "date-time" },
    "insurer": { "type": "object", "description": "Reference(Organization)" },
    "provider": { "type": "object", "description": "Reference(Practitioner|PractitionerRole|Organization)" },
    "outcome": { "type": "string", "enum": ["queued", "complete", "error", "partial"] },
    "disposition": { "type": "string" },
    "insurance": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "focal": { "type": "boolean" },
          "coverage": { "type": "object", "description": "Reference(Coverage)" }
        }
      }
    },
    "item": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "productOrService": { "type": "object" },
          "servicedDate": { "type": "string", "format": "date" },
          "servicedPeriod": { "type": "object" },
          "quantity": { "type": "object" },
          "unitPrice": { "type": "object" },
          "net": { "type": "object" },
          "adjudication": { "type": "array", "items": { "type": "object" } }
        }
      }
    },
    "total": { "type": "array", "items": { "type": "object" } },
    "payment": { "type": "object" }
  }
}