wellcare-health-plans · Schema

WellCare FHIR Explanation of Benefit

FHIR R4 ExplanationOfBenefit resource schema for WellCare Medicaid and Medicare Advantage adjudicated claims. Represents medical, pharmacy, dental, and vision claims.

Fortune 500

Properties

Name	Type	Description
resourceType	string
id	string
status	string
type	object	Claim type (pharmacy, oral, vision, institutional, professional).
patient	object
created	string
billablePeriod	object
item	array
total	array

View JSON Schema on GitHub

JSON Schema

{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://raw.githubusercontent.com/api-evangelist/wellcare-health-plans/main/json-schema/wellcare-fhir-eob-schema.json",
  "title": "WellCare FHIR Explanation of Benefit",
  "description": "FHIR R4 ExplanationOfBenefit resource schema for WellCare Medicaid and Medicare Advantage adjudicated claims. Represents medical, pharmacy, dental, and vision claims.",
  "type": "object",
  "properties": {
    "resourceType": {
      "type": "string",
      "const": "ExplanationOfBenefit"
    },
    "id": {
      "type": "string"
    },
    "status": {
      "type": "string",
      "enum": ["active", "cancelled", "draft", "entered-in-error"]
    },
    "type": {
      "type": "object",
      "description": "Claim type (pharmacy, oral, vision, institutional, professional).",
      "properties": {
        "coding": {
          "type": "array",
          "items": {
            "type": "object",
            "properties": {
              "system": { "type": "string" },
              "code": { "type": "string" },
              "display": { "type": "string" }
            }
          }
        }
      }
    },
    "patient": {
      "type": "object",
      "properties": {
        "reference": { "type": "string" }
      }
    },
    "created": {
      "type": "string",
      "format": "date"
    },
    "billablePeriod": {
      "type": "object",
      "properties": {
        "start": { "type": "string", "format": "date" },
        "end": { "type": "string", "format": "date" }
      }
    },
    "item": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "sequence": { "type": "integer" },
          "productOrService": {
            "type": "object",
            "properties": {
              "coding": {
                "type": "array",
                "items": {
                  "type": "object",
                  "properties": {
                    "system": { "type": "string" },
                    "code": { "type": "string" },
                    "display": { "type": "string" }
                  }
                }
              }
            }
          },
          "quantity": {
            "type": "object",
            "properties": {
              "value": { "type": "number" },
              "unit": { "type": "string" }
            }
          },
          "adjudication": {
            "type": "array",
            "items": {
              "type": "object",
              "properties": {
                "category": { "type": "object" },
                "amount": {
                  "type": "object",
                  "properties": {
                    "value": { "type": "number" },
                    "currency": { "type": "string" }
                  }
                }
              }
            }
          }
        }
      }
    },
    "total": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "category": { "type": "object" },
          "amount": {
            "type": "object",
            "properties": {
              "value": { "type": "number" },
              "currency": { "type": "string" }
            }
          }
        }
      }
    }
  },
  "required": ["resourceType", "id", "status", "type", "patient"]
}