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
{
"$schema": "https://json-schema.org/draft/2020-12/schema",
"$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"]
}
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