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
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
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
Search for ExplanationOfBenefit resources with GET [base]/ExplanationOfBenefit?patient=[id]&_lastUpdated=gt[date]; use _count and next-link pagination to handle large claims histories
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
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
Cross-reference ExplanationOfBenefit.insurance[].coverage to Coverage resources to determine the patient's plan at time of service
Known gotchas
CARIN BB defines multiple ExplanationOfBenefit profiles (Inpatient Institutional, Outpatient Institutional, Professional, Pharmacy); the profile is indicated by meta.profile — do not process all EOBs with the same parser
Adjudication category codes use CARIN BB-defined code systems (not X12 or standard FHIR codes); map them using the CARIN BB CodeSystem definitions, not generic EOB adjudication code mappings
CARIN BB requires patient authentication (not system-level backend services) to access EOB data; backend services access is not appropriate for patient-facing CARIN BB use cases
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