17236 lines
507 KiB
JSON
17236 lines
507 KiB
JSON
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|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
}
|
|
]
|
|
},
|
|
"net": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 28.104000000000003,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 112.41600000000001,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 3,
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
}
|
|
]
|
|
},
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
}
|
|
],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2010-04-12T12:22:44-04:00",
|
|
"end": "2010-04-12T12:52:44-04:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
}
|
|
]
|
|
},
|
|
"net": {
|
|
"value": 410.94,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 82.188,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 328.752,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 410.94,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 410.94,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"total": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
}
|
|
],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 441.168,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:d692e283-0833-3201-8e55-4f868a9c0736",
|
|
"resource": {
|
|
"resourceType": "Organization",
|
|
"id": "d692e283-0833-3201-8e55-4f868a9c0736",
|
|
"identifier": [
|
|
{
|
|
"system": "https://github.com/synthetichealth/synthea",
|
|
"value": "d692e283-0833-3201-8e55-4f868a9c0736"
|
|
}
|
|
],
|
|
"active": true,
|
|
"type": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
|
|
"code": "prov",
|
|
"display": "Healthcare Provider"
|
|
}
|
|
],
|
|
"text": "Healthcare Provider"
|
|
}
|
|
],
|
|
"name": "HALLMARK HEALTH SYSTEM",
|
|
"telecom": [
|
|
{
|
|
"system": "phone",
|
|
"value": "7819793000"
|
|
}
|
|
],
|
|
"address": [
|
|
{
|
|
"line": [
|
|
"585 LEBANON STREET"
|
|
],
|
|
"city": "MELROSE",
|
|
"state": "MA",
|
|
"postalCode": "02176",
|
|
"country": "US"
|
|
}
|
|
]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Organization"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:0000016d-3a85-4cca-0000-00000000010e",
|
|
"resource": {
|
|
"resourceType": "Practitioner",
|
|
"id": "0000016d-3a85-4cca-0000-00000000010e",
|
|
"identifier": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/us-npi",
|
|
"value": "270"
|
|
}
|
|
],
|
|
"active": true,
|
|
"name": [
|
|
{
|
|
"family": "Jenkins714",
|
|
"given": [
|
|
"Renato359"
|
|
],
|
|
"prefix": [
|
|
"Dr."
|
|
]
|
|
}
|
|
],
|
|
"telecom": [
|
|
{
|
|
"system": "email",
|
|
"value": "Renato359.Jenkins714@example.com",
|
|
"use": "work"
|
|
}
|
|
],
|
|
"address": [
|
|
{
|
|
"line": [
|
|
"585 LEBANON STREET"
|
|
],
|
|
"city": "MELROSE",
|
|
"state": "MA",
|
|
"postalCode": "02176",
|
|
"country": "US"
|
|
}
|
|
],
|
|
"gender": "male"
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Practitioner"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:3fba349b-e165-45f7-9cf2-66c391f293b6",
|
|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "3fba349b-e165-45f7-9cf2-66c391f293b6",
|
|
"status": "finished",
|
|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
|
|
"type": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "185345009",
|
|
"display": "Encounter for symptom"
|
|
}
|
|
],
|
|
"text": "Encounter for symptom"
|
|
}
|
|
],
|
|
"subject": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d",
|
|
"display": "Abraham100 Heller342"
|
|
},
|
|
"participant": [
|
|
{
|
|
"individual": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-00000000010e",
|
|
"display": "Dr. Renato359 Jenkins714"
|
|
}
|
|
}
|
|
],
|
|
"period": {
|
|
"start": "2010-10-05T12:22:44-04:00",
|
|
"end": "2010-10-05T12:37:44-04:00"
|
|
},
|
|
"reasonCode": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "444814009",
|
|
"display": "Viral sinusitis (disorder)"
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"serviceProvider": {
|
|
"reference": "urn:uuid:d692e283-0833-3201-8e55-4f868a9c0736",
|
|
"display": "HALLMARK HEALTH SYSTEM"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Encounter"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:cf39b665-4177-41e3-af34-149421cb895f",
|
|
"resource": {
|
|
"resourceType": "Condition",
|
|
"id": "cf39b665-4177-41e3-af34-149421cb895f",
|
|
"clinicalStatus": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
|
|
"code": "resolved"
|
|
}
|
|
]
|
|
},
|
|
"verificationStatus": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
|
|
"code": "confirmed"
|
|
}
|
|
]
|
|
},
|
|
"code": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "444814009",
|
|
"display": "Viral sinusitis (disorder)"
|
|
}
|
|
],
|
|
"text": "Viral sinusitis (disorder)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:3fba349b-e165-45f7-9cf2-66c391f293b6"
|
|
},
|
|
"onsetDateTime": "2010-10-05T12:22:44-04:00",
|
|
"abatementDateTime": "2010-10-12T12:22:44-04:00",
|
|
"recordedDate": "2010-10-05T12:22:44-04:00"
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Condition"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:54cc9fff-9f9c-4c63-ad3b-e65a807207d5",
|
|
"resource": {
|
|
"resourceType": "Claim",
|
|
"id": "54cc9fff-9f9c-4c63-ad3b-e65a807207d5",
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "institutional"
|
|
}
|
|
]
|
|
},
|
|
"use": "claim",
|
|
"patient": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d",
|
|
"display": "Abraham100 Heller342"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "2010-10-05T12:22:44-04:00",
|
|
"end": "2010-10-05T12:37:44-04:00"
|
|
},
|
|
"created": "2010-10-05T12:37:44-04:00",
|
|
"provider": {
|
|
"reference": "urn:uuid:d692e283-0833-3201-8e55-4f868a9c0736",
|
|
"display": "HALLMARK HEALTH SYSTEM"
|
|
},
|
|
"priority": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
|
|
"code": "normal"
|
|
}
|
|
]
|
|
},
|
|
"diagnosis": [
|
|
{
|
|
"sequence": 1,
|
|
"diagnosisReference": {
|
|
"reference": "urn:uuid:cf39b665-4177-41e3-af34-149421cb895f"
|
|
}
|
|
}
|
|
],
|
|
"insurance": [
|
|
{
|
|
"sequence": 1,
|
|
"focal": true,
|
|
"coverage": {
|
|
"display": "Aetna"
|
|
}
|
|
}
|
|
],
|
|
"item": [
|
|
{
|
|
"sequence": 1,
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "185345009",
|
|
"display": "Encounter for symptom"
|
|
}
|
|
],
|
|
"text": "Encounter for symptom"
|
|
},
|
|
"encounter": [
|
|
{
|
|
"reference": "urn:uuid:3fba349b-e165-45f7-9cf2-66c391f293b6"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 2,
|
|
"diagnosisSequence": [
|
|
1
|
|
],
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "444814009",
|
|
"display": "Viral sinusitis (disorder)"
|
|
}
|
|
],
|
|
"text": "Viral sinusitis (disorder)"
|
|
}
|
|
}
|
|
],
|
|
"total": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Claim"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:49408067-47c9-4ae6-9d4b-3597d942ef06",
|
|
"resource": {
|
|
"resourceType": "ExplanationOfBenefit",
|
|
"id": "49408067-47c9-4ae6-9d4b-3597d942ef06",
|
|
"contained": [
|
|
{
|
|
"resourceType": "ServiceRequest",
|
|
"id": "referral",
|
|
"status": "completed",
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"code": "21",
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"display": "Inpatient Hospital"
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|
}
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]
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},
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"net": {
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"value": 1898.04,
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},
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{
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{
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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}
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]
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},
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"amount": {
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"value": 379.608,
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}
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},
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{
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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}
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]
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},
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"amount": {
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"display": "Line Submitted Charge Amount"
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}
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]
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},
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"display": "Line Allowed Charge Amount"
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}
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]
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},
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"amount": {
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{
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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}
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]
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},
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"value": 0,
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"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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"display": "Line Processing Indicator Code"
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}
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]
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}
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}
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}
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],
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{
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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}
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],
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"text": "Submitted Amount"
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},
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}
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}
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}
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},
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}
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"code": "AMB"
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},
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{
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"coding": [
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{
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"system": "http://snomed.info/sct",
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|
"code": "410620009",
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"display": "Well child visit (procedure)"
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}
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|
],
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"text": "Well child visit (procedure)"
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}
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],
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"display": "Abraham100 Heller342"
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{
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"individual": {
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"display": "Dr. Mariela993 Schamberger479"
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}
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],
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},
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},
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{
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{
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"code": "active"
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
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}
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"display": "Body Height"
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}
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],
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"text": "Body Height"
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},
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|
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|
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|
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|
}
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|
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"code": "kg/m2"
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},
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|
],
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|
"code": {
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|
"coding": [
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|
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|
"system": "http://loinc.org",
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|
"code": "59576-9",
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|
"display": "Body mass index (BMI) [Percentile] Per age and gender"
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|
}
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|
],
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|
"text": "Body mass index (BMI) [Percentile] Per age and gender"
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|
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"valueQuantity": {
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|
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|
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|
"code": "%"
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|
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|
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"code": "vital-signs",
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"display": "vital-signs"
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}
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|
],
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|
"code": {
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|
"coding": [
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|
"system": "http://loinc.org",
|
|
"code": "55284-4",
|
|
"display": "Blood Pressure"
|
|
}
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|
],
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|
"text": "Blood Pressure"
|
|
},
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"component": [
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{
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"coding": [
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|
{
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|
"system": "http://loinc.org",
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|
"code": "8462-4",
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|
"display": "Diastolic Blood Pressure"
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|
}
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|
],
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|
"text": "Diastolic Blood Pressure"
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|
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|
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|
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"code": "mm[Hg]"
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{
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"code": {
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|
{
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|
"system": "http://loinc.org",
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|
"code": "8480-6",
|
|
"display": "Systolic Blood Pressure"
|
|
}
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|
],
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|
"text": "Systolic Blood Pressure"
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|
},
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|
"valueQuantity": {
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|
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{
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}
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{
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}
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{
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{
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"system": "http://hl7.org/fhir/sid/cvx",
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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},
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"display": "Line Beneficiary Coinsurance Amount"
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}
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]
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},
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{
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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]
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]
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},
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"amount": {
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{
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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}
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]
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{
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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}
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{
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]
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}
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{
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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{
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"system": "http://snomed.info/sct",
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"code": "162864005",
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"display": "Body mass index 30+ - obesity (finding)"
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}
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],
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{
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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}
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]
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}
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}
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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}
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],
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"name": "PROMPT CARE WALK-IN CLINIC",
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{
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"system": "phone",
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"value": "781-306-6180"
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}
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],
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{
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"line": [
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"170 GOVERNORS AVENUE"
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],
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},
|
|
{
|
|
"fullUrl": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c",
|
|
"resource": {
|
|
"resourceType": "Practitioner",
|
|
"id": "0000016d-3a85-4cca-0000-000000016d8c",
|
|
"identifier": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/us-npi",
|
|
"value": "93580"
|
|
}
|
|
],
|
|
"active": true,
|
|
"name": [
|
|
{
|
|
"family": "Prohaska837",
|
|
"given": [
|
|
"Candyce305"
|
|
],
|
|
"prefix": [
|
|
"Dr."
|
|
]
|
|
}
|
|
],
|
|
"telecom": [
|
|
{
|
|
"system": "email",
|
|
"value": "Candyce305.Prohaska837@example.com",
|
|
"use": "work"
|
|
}
|
|
],
|
|
"address": [
|
|
{
|
|
"line": [
|
|
"170 GOVERNORS AVENUE"
|
|
],
|
|
"city": "MEDFORD",
|
|
"state": "MA",
|
|
"postalCode": "2155",
|
|
"country": "US"
|
|
}
|
|
],
|
|
"gender": "female"
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Practitioner"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:cd4bfc24-8fff-4eb0-bd93-3c7054551514",
|
|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "cd4bfc24-8fff-4eb0-bd93-3c7054551514",
|
|
"status": "finished",
|
|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
|
|
"type": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "702927004",
|
|
"display": "Urgent care clinic (procedure)"
|
|
}
|
|
],
|
|
"text": "Urgent care clinic (procedure)"
|
|
}
|
|
],
|
|
"subject": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d",
|
|
"display": "Abraham100 Heller342"
|
|
},
|
|
"participant": [
|
|
{
|
|
"individual": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c",
|
|
"display": "Dr. Candyce305 Prohaska837"
|
|
}
|
|
}
|
|
],
|
|
"period": {
|
|
"start": "2013-09-30T12:22:44-04:00",
|
|
"end": "2013-09-30T12:37:44-04:00"
|
|
},
|
|
"serviceProvider": {
|
|
"reference": "urn:uuid:90cf148c-69ed-3d33-aa86-b509c6b0b25f",
|
|
"display": "PROMPT CARE WALK-IN CLINIC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Encounter"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:23e0e3e8-0a58-4545-ac23-759912398535",
|
|
"resource": {
|
|
"resourceType": "Immunization",
|
|
"id": "23e0e3e8-0a58-4545-ac23-759912398535",
|
|
"status": "completed",
|
|
"vaccineCode": {
|
|
"coding": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "62",
|
|
"display": "HPV, quadrivalent"
|
|
}
|
|
],
|
|
"text": "HPV, quadrivalent"
|
|
},
|
|
"patient": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:cd4bfc24-8fff-4eb0-bd93-3c7054551514"
|
|
},
|
|
"occurrenceDateTime": "2013-09-30T12:22:44-04:00",
|
|
"primarySource": true
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Immunization"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:fa15b28e-f188-43e2-839e-bdc8a3a8b344",
|
|
"resource": {
|
|
"resourceType": "Claim",
|
|
"id": "fa15b28e-f188-43e2-839e-bdc8a3a8b344",
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "institutional"
|
|
}
|
|
]
|
|
},
|
|
"use": "claim",
|
|
"patient": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d",
|
|
"display": "Abraham100 Heller342"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "2013-09-30T12:22:44-04:00",
|
|
"end": "2013-09-30T12:37:44-04:00"
|
|
},
|
|
"created": "2013-09-30T12:37:44-04:00",
|
|
"provider": {
|
|
"reference": "urn:uuid:90cf148c-69ed-3d33-aa86-b509c6b0b25f",
|
|
"display": "PROMPT CARE WALK-IN CLINIC"
|
|
},
|
|
"priority": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
|
|
"code": "normal"
|
|
}
|
|
]
|
|
},
|
|
"supportingInfo": [
|
|
{
|
|
"sequence": 1,
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
|
|
"code": "info"
|
|
}
|
|
]
|
|
},
|
|
"valueReference": {
|
|
"reference": "urn:uuid:23e0e3e8-0a58-4545-ac23-759912398535"
|
|
}
|
|
}
|
|
],
|
|
"insurance": [
|
|
{
|
|
"sequence": 1,
|
|
"focal": true,
|
|
"coverage": {
|
|
"display": "Aetna"
|
|
}
|
|
}
|
|
],
|
|
"item": [
|
|
{
|
|
"sequence": 1,
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "702927004",
|
|
"display": "Urgent care clinic (procedure)"
|
|
}
|
|
],
|
|
"text": "Urgent care clinic (procedure)"
|
|
},
|
|
"encounter": [
|
|
{
|
|
"reference": "urn:uuid:cd4bfc24-8fff-4eb0-bd93-3c7054551514"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 2,
|
|
"informationSequence": [
|
|
1
|
|
],
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "62",
|
|
"display": "HPV, quadrivalent"
|
|
}
|
|
],
|
|
"text": "HPV, quadrivalent"
|
|
},
|
|
"net": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
],
|
|
"total": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Claim"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:01b2032e-a8a3-4b1c-b5ce-2f860dab4102",
|
|
"resource": {
|
|
"resourceType": "ExplanationOfBenefit",
|
|
"id": "01b2032e-a8a3-4b1c-b5ce-2f860dab4102",
|
|
"contained": [
|
|
{
|
|
"resourceType": "ServiceRequest",
|
|
"id": "referral",
|
|
"status": "completed",
|
|
"intent": "order",
|
|
"subject": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"requester": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c"
|
|
},
|
|
"performer": [
|
|
{
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Aetna"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"payor": [
|
|
{
|
|
"display": "Aetna"
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"identifier": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "fa15b28e-f188-43e2-839e-bdc8a3a8b344"
|
|
},
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
|
|
"value": "99999999999"
|
|
}
|
|
],
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "institutional"
|
|
}
|
|
]
|
|
},
|
|
"use": "claim",
|
|
"patient": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "2013-09-30T12:37:44-04:00",
|
|
"end": "2014-09-30T12:37:44-04:00"
|
|
},
|
|
"created": "2013-09-30T12:37:44-04:00",
|
|
"insurer": {
|
|
"display": "Aetna"
|
|
},
|
|
"provider": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:fa15b28e-f188-43e2-839e-bdc8a3a8b344"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [
|
|
{
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000016d8c"
|
|
},
|
|
"role": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary Care Practitioner"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
],
|
|
"insurance": [
|
|
{
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Aetna"
|
|
}
|
|
}
|
|
],
|
|
"item": [
|
|
{
|
|
"sequence": 1,
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
}
|
|
]
|
|
},
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "702927004",
|
|
"display": "Urgent care clinic (procedure)"
|
|
}
|
|
],
|
|
"text": "Urgent care clinic (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2013-09-30T12:22:44-04:00",
|
|
"end": "2013-09-30T12:37:44-04:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "20",
|
|
"display": "Urgent Care Facility"
|
|
}
|
|
]
|
|
},
|
|
"encounter": [
|
|
{
|
|
"reference": "urn:uuid:cd4bfc24-8fff-4eb0-bd93-3c7054551514"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 2,
|
|
"informationSequence": [
|
|
1
|
|
],
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
}
|
|
]
|
|
},
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "62",
|
|
"display": "HPV, quadrivalent"
|
|
}
|
|
],
|
|
"text": "HPV, quadrivalent"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2013-09-30T12:22:44-04:00",
|
|
"end": "2013-09-30T12:37:44-04:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "20",
|
|
"display": "Urgent Care Facility"
|
|
}
|
|
]
|
|
},
|
|
"net": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 28.104000000000003,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 112.41600000000001,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"total": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
}
|
|
],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 112.41600000000001,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:9f4e40e3-6f6b-4959-b407-3926e9ed049c",
|
|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "9f4e40e3-6f6b-4959-b407-3926e9ed049c",
|
|
"status": "finished",
|
|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
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|
|
},
|
|
"supportingInfo": [
|
|
{
|
|
"sequence": 1,
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
|
|
"code": "info"
|
|
}
|
|
]
|
|
},
|
|
"valueReference": {
|
|
"reference": "urn:uuid:36b1cf87-a6e8-4271-8350-cf230ac8361d"
|
|
}
|
|
}
|
|
],
|
|
"insurance": [
|
|
{
|
|
"sequence": 1,
|
|
"focal": true,
|
|
"coverage": {
|
|
"display": "Aetna"
|
|
}
|
|
}
|
|
],
|
|
"item": [
|
|
{
|
|
"sequence": 1,
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
}
|
|
],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"encounter": [
|
|
{
|
|
"reference": "urn:uuid:92b439da-6fdd-48e5-aa8d-b0543f840a1b"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 2,
|
|
"informationSequence": [
|
|
1
|
|
],
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
}
|
|
],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"net": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
],
|
|
"total": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Claim"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:693eaeb7-6dc9-49c3-9a9a-d44995564fab",
|
|
"resource": {
|
|
"resourceType": "ExplanationOfBenefit",
|
|
"id": "693eaeb7-6dc9-49c3-9a9a-d44995564fab",
|
|
"contained": [
|
|
{
|
|
"resourceType": "ServiceRequest",
|
|
"id": "referral",
|
|
"status": "completed",
|
|
"intent": "order",
|
|
"subject": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"requester": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000000636"
|
|
},
|
|
"performer": [
|
|
{
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000000636"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Aetna"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"payor": [
|
|
{
|
|
"display": "Aetna"
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"identifier": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "19aa41e4-5be8-469b-886e-a4c13a1d91c2"
|
|
},
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
|
|
"value": "99999999999"
|
|
}
|
|
],
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "institutional"
|
|
}
|
|
]
|
|
},
|
|
"use": "claim",
|
|
"patient": {
|
|
"reference": "urn:uuid:b426b062-8273-4b93-a907-de3176c0567d"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "2019-06-03T12:37:44-04:00",
|
|
"end": "2020-06-03T12:37:44-04:00"
|
|
},
|
|
"created": "2019-06-03T12:37:44-04:00",
|
|
"insurer": {
|
|
"display": "Aetna"
|
|
},
|
|
"provider": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000000636"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:19aa41e4-5be8-469b-886e-a4c13a1d91c2"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [
|
|
{
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "urn:uuid:0000016d-3a85-4cca-0000-000000000636"
|
|
},
|
|
"role": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary Care Practitioner"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
],
|
|
"insurance": [
|
|
{
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Aetna"
|
|
}
|
|
}
|
|
],
|
|
"item": [
|
|
{
|
|
"sequence": 1,
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
}
|
|
]
|
|
},
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
}
|
|
],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2019-06-03T12:22:44-04:00",
|
|
"end": "2019-06-03T12:37:44-04:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
}
|
|
]
|
|
},
|
|
"encounter": [
|
|
{
|
|
"reference": "urn:uuid:92b439da-6fdd-48e5-aa8d-b0543f840a1b"
|
|
}
|
|
]
|
|
},
|
|
{
|
|
"sequence": 2,
|
|
"informationSequence": [
|
|
1
|
|
],
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
}
|
|
]
|
|
},
|
|
"productOrService": {
|
|
"coding": [
|
|
{
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
}
|
|
],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2019-06-03T12:22:44-04:00",
|
|
"end": "2019-06-03T12:37:44-04:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
}
|
|
]
|
|
},
|
|
"net": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 28.104000000000003,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 112.41600000000001,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 140.52,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
}
|
|
]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
}
|
|
]
|
|
}
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"total": [
|
|
{
|
|
"category": {
|
|
"coding": [
|
|
{
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
}
|
|
],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 129.16,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 112.41600000000001,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
}
|
|
]
|
|
}
|