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ExplanationOfBenefit "203" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Generated Narrative with Details

id: 203

contained: ,

identifier: , 99999999999

status: active

type: Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim (Details : {https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd code "71" := "71", given as "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"}; {https://bluebutton.cms.gov/resources/codesystem/eob-type code "CARRIER" := "CARRIER", given as "EOB Type"}; {http://hl7.org/fhir/ex-claimtype code "professional" := "professional", given as "Claim Type"}; {https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd code "O" := "O", given as "Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)"})

patient: Patient/10051430

billablePeriod: 11/15/1965 8:07:41 AM --> 11/15/1966 8:07:41 AM

created: 11/15/1965 8:07:41 AM

provider:

organization:

referral: #1

claim: Claim/205

totalCost: 129.16 USD (Details: urn:iso:std:iso:4217 code USD := "USD")


<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="203"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2020-07-14T10:16:56.078Z"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>
        <b>Generated Narrative with Details</b>
      </p>
      <p>
        <b>id</b>: 203</p>
      <p>
        <b>contained</b>: , </p>
      <p>
        <b>identifier</b>: , 99999999999</p>
      <p>
        <b>status</b>: active</p>
      <p>
        <b>type</b>: Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim
        <span style="background: LightGoldenRodYellow ">(Details : {https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd code "71" := "71", given as "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"} {https://bluebutton.cms.gov/resources/codesystem/eob-type code "CARRIER" := "CARRIER", given as "EOB Type"} {http://hl7.org/fhir/ex-claimtype code "professional" := "professional", given as "Claim Type"} {https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd code "O" := "O", given as "Part B physician/supplier claim record (processed by local carriers can include DMEPOS services)"})</span>
      </p>
      <p>
        <b>patient</b>:
        <a href="Patient/10051430">Patient/10051430</a>
      </p>
      <p>
        <b>billablePeriod</b>: 11/15/1965 8:07:41 AM --&gt; 11/15/1966 8:07:41 AM</p>
      <p>
        <b>created</b>: 11/15/1965 8:07:41 AM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="Claim/205">Claim/205</a>
      </p>
      <p>
        <b>totalCost</b>: 129.16 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <ReferralRequest>
      <id value="1"/>
      <status value="completed"/>
      <intent value="order"/>
      <subject>
        <reference value="Patient/10051430"/>
      </subject>
      <requester>
        <agent>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi"/>
            <value value="99999999"/>
          </identifier>
        </agent>
      </requester>
      <recipient>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="99999999"/>
        </identifier>
      </recipient>
    </ReferralRequest>
  </contained>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Humana"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="fea35dc5-7804-4f84-9401-d3682d9efb56"/>
  </identifier>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/identifier/claim-group"/>
    <value value="99999999999"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd"/>
      <code value="71"/>
      <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"/>
    </coding>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type"/>
      <code value="CARRIER"/>
      <display value="EOB Type"/>
    </coding>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="professional"/>
      <display value="Claim Type"/>
    </coding>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd"/>
      <code value="O"/>
      <display value="Part B physician/supplier claim record (processed by local carriers can include DMEPOS services)"/>
    </coding>
  </type>
  <patient>
    <reference value="Patient/10051430"/>
  </patient>
  <billablePeriod>
    <start value="1965-11-15T08:07:41-05:00"/>
    <end value="1966-11-15T08:07:41-05:00"/>
  </billablePeriod>
  <created value="1965-11-15T08:07:41-05:00"/>
  <provider>
    <identifier>
      <value value="0000016d-3a85-4cca-0000-000000000122"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="8ad64ecf-c817-3753-bee7-006a8e662e06"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="Claim/205"/>
  </claim>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <identifier>
        <system value="http://hl7.org/fhir/sid/us-npi"/>
        <value value="99999999"/>
      </identifier>
    </provider>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="primary"/>
        <display value="Primary Care Practitioner"/>
      </coding>
    </role>
  </careTeam>
  <diagnosis>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1"/>
        <code value="Y"/>
        <display value="Diagnosis present at time of admission"/>
      </valueCoding>
    </extension>
    <sequence value="1"/>
    <diagnosisReference>
      <reference value="urn:uuid:566d4250-83ff-44fd-81e9-8ed99085f046"/>
    </diagnosisReference>
    <type>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/codesystem/diagnosis-type"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <diagnosis>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1"/>
        <code value="Y"/>
        <display value="Diagnosis present at time of admission"/>
      </valueCoding>
    </extension>
    <sequence value="2"/>
    <diagnosisReference>
      <reference value="urn:uuid:4d50aaaa-0f7c-4139-9554-482e455d08fa"/>
    </diagnosisReference>
    <type>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/codesystem/diagnosis-type"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
    <encounter>
      <reference value="Encounter/821310"/>
    </encounter>
  </item>
  <item>
    <sequence value="2"/>
    <diagnosisLinkId value="1"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="3"/>
    <diagnosisLinkId value="2"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "202" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Generated Narrative with Details

id: 202

contained: ,

identifier: , 99999999999

status: active

type: Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim (Details : {https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd code "71" := "71", given as "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"}; {https://bluebutton.cms.gov/resources/codesystem/eob-type code "CARRIER" := "CARRIER", given as "EOB Type"}; {http://hl7.org/fhir/ex-claimtype code "professional" := "professional", given as "Claim Type"}; {https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd code "O" := "O", given as "Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)"})

patient: Patient/10051429

billablePeriod: 11/15/1965 8:07:41 AM --> 11/15/1966 8:07:41 AM

created: 11/15/1965 8:07:41 AM

provider:

organization:

referral: #1

claim: Claim/203

totalCost: 129.16 USD (Details: urn:iso:std:iso:4217 code USD := "USD")


<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="202"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2020-07-14T10:11:00.156Z"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>
        <b>Generated Narrative with Details</b>
      </p>
      <p>
        <b>id</b>: 202</p>
      <p>
        <b>contained</b>: , </p>
      <p>
        <b>identifier</b>: , 99999999999</p>
      <p>
        <b>status</b>: active</p>
      <p>
        <b>type</b>: Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim
        <span style="background: LightGoldenRodYellow ">(Details : {https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd code "71" := "71", given as "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"} {https://bluebutton.cms.gov/resources/codesystem/eob-type code "CARRIER" := "CARRIER", given as "EOB Type"} {http://hl7.org/fhir/ex-claimtype code "professional" := "professional", given as "Claim Type"} {https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd code "O" := "O", given as "Part B physician/supplier claim record (processed by local carriers can include DMEPOS services)"})</span>
      </p>
      <p>
        <b>patient</b>:
        <a href="Patient/10051429">Patient/10051429</a>
      </p>
      <p>
        <b>billablePeriod</b>: 11/15/1965 8:07:41 AM --&gt; 11/15/1966 8:07:41 AM</p>
      <p>
        <b>created</b>: 11/15/1965 8:07:41 AM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="Claim/203">Claim/203</a>
      </p>
      <p>
        <b>totalCost</b>: 129.16 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <ReferralRequest>
      <id value="1"/>
      <status value="completed"/>
      <intent value="order"/>
      <subject>
        <reference value="Patient/10051429"/>
      </subject>
      <requester>
        <agent>
          <identifier>
            <system value="http://hl7.org/fhir/sid/us-npi"/>
            <value value="99999999"/>
          </identifier>
        </agent>
      </requester>
      <recipient>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="99999999"/>
        </identifier>
      </recipient>
    </ReferralRequest>
  </contained>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Humana"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="fea35dc5-7804-4f84-9401-d3682d9efb56"/>
  </identifier>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/identifier/claim-group"/>
    <value value="99999999999"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd"/>
      <code value="71"/>
      <display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"/>
    </coding>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/codesystem/eob-type"/>
      <code value="CARRIER"/>
      <display value="EOB Type"/>
    </coding>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="professional"/>
      <display value="Claim Type"/>
    </coding>
    <coding>
      <system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd"/>
      <code value="O"/>
      <display value="Part B physician/supplier claim record (processed by local carriers can include DMEPOS services)"/>
    </coding>
  </type>
  <patient>
    <reference value="Patient/10051429"/>
  </patient>
  <billablePeriod>
    <start value="1965-11-15T08:07:41-05:00"/>
    <end value="1966-11-15T08:07:41-05:00"/>
  </billablePeriod>
  <created value="1965-11-15T08:07:41-05:00"/>
  <provider>
    <identifier>
      <value value="0000016d-3a85-4cca-0000-000000000122"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="8ad64ecf-c817-3753-bee7-006a8e662e06"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="Claim/203"/>
  </claim>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <identifier>
        <system value="http://hl7.org/fhir/sid/us-npi"/>
        <value value="99999999"/>
      </identifier>
    </provider>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="primary"/>
        <display value="Primary Care Practitioner"/>
      </coding>
    </role>
  </careTeam>
  <diagnosis>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1"/>
        <code value="Y"/>
        <display value="Diagnosis present at time of admission"/>
      </valueCoding>
    </extension>
    <sequence value="1"/>
    <diagnosisReference>
      <reference value="urn:uuid:566d4250-83ff-44fd-81e9-8ed99085f046"/>
    </diagnosisReference>
    <type>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/codesystem/diagnosis-type"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <diagnosis>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1"/>
        <code value="Y"/>
        <display value="Diagnosis present at time of admission"/>
      </valueCoding>
    </extension>
    <sequence value="2"/>
    <diagnosisReference>
      <reference value="urn:uuid:4d50aaaa-0f7c-4139-9554-482e455d08fa"/>
    </diagnosisReference>
    <type>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/codesystem/diagnosis-type"/>
        <code value="principal"/>
      </coding>
    </type>
  </diagnosis>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
    <encounter>
      <reference value="Encounter/821309"/>
    </encounter>
  </item>
  <item>
    <sequence value="2"/>
    <diagnosisLinkId value="1"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <sequence value="3"/>
    <diagnosisLinkId value="2"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <servicedPeriod>
      <start value="1965-11-15T06:22:41-05:00"/>
      <end value="1965-11-15T08:07:41-05:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="23"/>
        <display value="Emergency Room"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>