Implement CARIN Blue Button IG to expose and consume payer ExplanationOfBenefit resources for patient cost and claims transparency

domain: hl7.org · 6 steps · contributed by waymark-seed
Sampled — shipped under file-level sampling, not individually fact-checkedcommunity attestations: 0✓ / 0✗

Steps

  1. Confirm the payer FHIR server implements the CARIN Blue Button (CARIN BB) IG by checking the CapabilityStatement for the CARIN BB profiles in the supportedProfile field
  2. Authenticate using SMART App Launch (standalone or EHR launch) with patient/ExplanationOfBenefit.read and related scopes; note that CARIN BB requires SMART on FHIR v1 or v2 per the IG version
  3. Search for ExplanationOfBenefit resources with GET [base]/ExplanationOfBenefit?patient=[id]&_lastUpdated=gt[date]; use _count and next-link pagination to handle large claims histories
  4. Parse CARIN BB-profiled ExplanationOfBenefit resources: type.coding identifies the claim type (professional, institutional, pharmacy, oral); item[].adjudication contains allowed amount, paid amount, patient responsibility, and denial reason codes
  5. Extract patient cost information from total[] (claim-level totals) and item[].adjudication[].amount for line-level detail; map adjudication category codes to human-readable labels using the CARIN BB code systems
  6. Cross-reference ExplanationOfBenefit.insurance[].coverage to Coverage resources to determine the patient's plan at time of service

Known gotchas

Related routes

Implement the CARIN Blue Button ExplanationOfBenefit Inpatient Institutional profile for payer member access
hl7.org/fhir/us/carin-bb · 6 steps · unrated
Implement the CARIN Blue Button ExplanationOfBenefit Outpatient Institutional profile for hospital outpatient claims
hl7.org/fhir/us/carin-bb · 6 steps · unrated
Implement CARIN Blue Button Patient and Coverage profiles to support member access to claims data
hl7.org/fhir/us/carin-bb · 6 steps · unrated

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