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ExplanationOfBenefit "c2a54e42-807a-0f49-d449-8285a41bad7b" 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: c2a54e42-807a-0f49-d449-8285a41bad7b

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/d84fb5f6-2b51-a331-11a1-ca90d761720e

billablePeriod: 9/2/2012 2:14:12 PM --> 9/2/2013 2:14:12 PM

created: 9/2/2012 2:14:12 PM

provider:

organization:

referral: #1

claim: Claim/87d31926-e421-3523-4880-9e6560bec124

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="c2a54e42-807a-0f49-d449-8285a41bad7b"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:35:02.860Z"/>
  </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>: c2a54e42-807a-0f49-d449-8285a41bad7b</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/d84fb5f6-2b51-a331-11a1-ca90d761720e">Patient/d84fb5f6-2b51-a331-11a1-ca90d761720e</a>
      </p>
      <p>
        <b>billablePeriod</b>: 9/2/2012 2:14:12 PM --&gt; 9/2/2013 2:14:12 PM</p>
      <p>
        <b>created</b>: 9/2/2012 2:14:12 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="Claim/87d31926-e421-3523-4880-9e6560bec124">Claim/87d31926-e421-3523-4880-9e6560bec124</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/d84fb5f6-2b51-a331-11a1-ca90d761720e"/>
      </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="Medicaid"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="87d31926-e421-3523-4880-9e6560bec124"/>
  </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/d84fb5f6-2b51-a331-11a1-ca90d761720e"/>
  </patient>
  <billablePeriod>
    <start value="2012-09-02T14:14:12+02:00"/>
    <end value="2013-09-02T14:14:12+02:00"/>
  </billablePeriod>
  <created value="2012-09-02T14:14:12+02:00"/>
  <provider>
    <identifier>
      <value value="1ccd1f11-55bb-3b99-a896-6c70d03e306f"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="92819cdc-db9e-387e-8c4f-4b2b4e8b2e4f"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="Claim/87d31926-e421-3523-4880-9e6560bec124"/>
  </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>
  <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="2012-09-02T13:59:12+02:00"/>
      <end value="2012-09-02T14:14:12+02:00"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="20"/>
        <display value="Urgent Care Facility"/>
      </coding>
    </locationCodeableConcept>
    <encounter>
      <reference value="Encounter/44c6c9f5-c206-34ae-dedb-11f8aef90819"/>
    </encounter>
  </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 "235c356b-e94a-4c05-2800-d69c796f3fbd" 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: 235c356b-e94a-4c05-2800-d69c796f3fbd

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 9/11/2020 3:08:44 PM --> 9/11/2021 3:08:44 PM

created: 9/11/2020 3:08:44 PM

provider:

organization:

referral: #1

claim: urn:uuid:f3292122-7c5f-4fc0-a74a-90104e0dc6db

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="235c356b-e94a-4c05-2800-d69c796f3fbd"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:18.688Z"/>
  </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>: 235c356b-e94a-4c05-2800-d69c796f3fbd</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 9/11/2020 3:08:44 PM --&gt; 9/11/2021 3:08:44 PM</p>
      <p>
        <b>created</b>: 9/11/2020 3:08:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="urn:uuid:f3292122-7c5f-4fc0-a74a-90104e0dc6db">urn:uuid:f3292122-7c5f-4fc0-a74a-90104e0dc6db</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
      </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="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="f3292122-7c5f-4fc0-a74a-90104e0dc6db"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <start value="2020-09-11T15:08:44+02:00"/>
    <end value="2021-09-11T15:08:44+02:00"/>
  </billablePeriod>
  <created value="2020-09-11T15:08:44+02:00"/>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="urn:uuid:f3292122-7c5f-4fc0-a74a-90104e0dc6db"/>
  </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:e19ddaba-793a-fe71-d855-829d33098f02"/>
    </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="2020-09-11T14:08:44+02:00"/>
      <end value="2020-09-11T15:08:44+02:00"/>
    </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="urn:uuid:c64e66e6-7d6a-ce05-3808-b8fed45e66dd"/>
    </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="2020-09-11T14:08:44+02:00"/>
      <end value="2020-09-11T15:08:44+02:00"/>
    </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 "e0fe9ce7-ba1e-acdc-113b-b3ed1d14767a" 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: e0fe9ce7-ba1e-acdc-113b-b3ed1d14767a

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 8/6/2020 2:11:44 PM --> 8/6/2021 2:11:44 PM

provider:

organization:

totalCost: 77.49 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="e0fe9ce7-ba1e-acdc-113b-b3ed1d14767a"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:18.204Z"/>
  </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>: e0fe9ce7-ba1e-acdc-113b-b3ed1d14767a</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 8/6/2020 2:11:44 PM --&gt; 8/6/2021 2:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="e53ebd7f-e6fe-6de0-6e84-f307c888dfc2"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2020-08-06T14:11:44+02:00"/>
    <end value="2021-08-06T14:11:44+02:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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:50935d4e-1504-3764-e902-1baa3f605c2f"/>
    </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>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <service>
      <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension">
        <valueCoding>
          <system value="https://www.accessdata.fda.gov/scripts/cder/ndc"/>
          <code value="0624"/>
          <display value="Dummy"/>
        </valueCoding>
      </extension>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="117015009"/>
      </coding>
    </service>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="520.6220000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="2082.4880000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="2603.11"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="2603.11"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="77.49"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="2082.4880000000003"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "bfddc011-ba7c-eee0-50cc-8603038c247c" 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: bfddc011-ba7c-eee0-50cc-8603038c247c

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 2/23/2020 2:13:44 PM --> 2/23/2021 2:13:44 PM

provider:

organization:

totalCost: 77.49 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="bfddc011-ba7c-eee0-50cc-8603038c247c"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:17.766Z"/>
  </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>: bfddc011-ba7c-eee0-50cc-8603038c247c</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 2/23/2020 2:13:44 PM --&gt; 2/23/2021 2:13:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="7203581e-0d08-0548-9a6a-0c19979d3e78"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2020-02-23T14:13:44+01:00"/>
    <end value="2021-02-23T14:13:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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:1a540b9f-187a-e014-c624-6ce59f15ecf9"/>
    </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:e4078478-e957-ba05-66e9-e63b746e18fa"/>
    </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="3"/>
    <diagnosisReference>
      <reference value="urn:uuid:88bf61ad-19de-2a34-8e5a-c3cadfdbac3e"/>
    </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="4"/>
    <diagnosisReference>
      <reference value="urn:uuid:876b27a2-68b0-ac82-b953-e1269e07b1e8"/>
    </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="5"/>
    <diagnosisReference>
      <reference value="urn:uuid:62940d07-963d-a8a3-d36b-019a34cd4e7a"/>
    </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="6"/>
    <diagnosisReference>
      <reference value="urn:uuid:661f9009-0e95-b148-7112-0a79f8110d9a"/>
    </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>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="4"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="5"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="6"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="7"/>
    <service>
      <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension">
        <valueCoding>
          <system value="https://www.accessdata.fda.gov/scripts/cder/ndc"/>
          <code value="0624"/>
          <display value="Dummy"/>
        </valueCoding>
      </extension>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="261352009"/>
      </coding>
    </service>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0.25"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="1.0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="1.25"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="1.25"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="8"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="77.49"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="1.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "b7c62c45-8a15-6385-09fb-ba146e149441" 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: b7c62c45-8a15-6385-09fb-ba146e149441

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 2/3/2020 1:11:44 PM --> 2/3/2021 1:11:44 PM

provider:

organization:

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="b7c62c45-8a15-6385-09fb-ba146e149441"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:15.377Z"/>
  </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>: b7c62c45-8a15-6385-09fb-ba146e149441</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 2/3/2020 1:11:44 PM --&gt; 2/3/2021 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="1b425f07-c633-6394-e04a-e49de4fbd7c2"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2020-02-03T13:11:44+01:00"/>
    <end value="2021-02-03T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <service>
      <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension">
        <valueCoding>
          <system value="https://www.accessdata.fda.gov/scripts/cder/ndc"/>
          <code value="0624"/>
          <display value="Dummy"/>
        </valueCoding>
      </extension>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="430193006"/>
      </coding>
    </service>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="114.984"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="459.936"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="574.92"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="574.92"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="572.352"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "1abb34b8-773a-b22c-14ba-3eadfac05559" 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: 1abb34b8-773a-b22c-14ba-3eadfac05559

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/28/2019 1:11:44 PM --> 1/28/2020 1:11:44 PM

provider:

organization:

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="1abb34b8-773a-b22c-14ba-3eadfac05559"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:14.469Z"/>
  </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>: 1abb34b8-773a-b22c-14ba-3eadfac05559</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/28/2019 1:11:44 PM --&gt; 1/28/2020 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="5de035c5-df6a-8f79-2f15-50f587fb8a59"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2019-01-28T13:11:44+01:00"/>
    <end value="2020-01-28T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="112.41600000000001"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "f4d45b2f-cef3-83f9-f0ab-84712cac1260" 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: f4d45b2f-cef3-83f9-f0ab-84712cac1260

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 10/22/2018 2:23:44 PM --> 10/22/2019 2:23:44 PM

provider:

organization:

totalCost: 77.49 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="f4d45b2f-cef3-83f9-f0ab-84712cac1260"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:12.907Z"/>
  </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>: f4d45b2f-cef3-83f9-f0ab-84712cac1260</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 10/22/2018 2:23:44 PM --&gt; 10/22/2019 2:23:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="dab67af2-dfb2-3863-eca7-ef853afb9312"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2018-10-22T14:23:44+02:00"/>
    <end value="2019-10-22T14:23:44+02:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="77.49"/>
    <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 "4f4b9b67-aeb1-ecfb-cfa4-530867dd22c8" 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: 4f4b9b67-aeb1-ecfb-cfa4-530867dd22c8

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 10/1/2018 3:08:44 PM --> 10/1/2019 3:08:44 PM

created: 10/1/2018 3:08:44 PM

provider:

organization:

referral: #1

claim: urn:uuid:922578b9-1f56-1f9e-4efb-ead67fac633d

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="4f4b9b67-aeb1-ecfb-cfa4-530867dd22c8"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:12.672Z"/>
  </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>: 4f4b9b67-aeb1-ecfb-cfa4-530867dd22c8</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 10/1/2018 3:08:44 PM --&gt; 10/1/2019 3:08:44 PM</p>
      <p>
        <b>created</b>: 10/1/2018 3:08:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="urn:uuid:922578b9-1f56-1f9e-4efb-ead67fac633d">urn:uuid:922578b9-1f56-1f9e-4efb-ead67fac633d</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
      </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="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="922578b9-1f56-1f9e-4efb-ead67fac633d"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <start value="2018-10-01T15:08:44+02:00"/>
    <end value="2019-10-01T15:08:44+02:00"/>
  </billablePeriod>
  <created value="2018-10-01T15:08:44+02:00"/>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="urn:uuid:922578b9-1f56-1f9e-4efb-ead67fac633d"/>
  </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:f25665bf-0746-904e-2172-d61dd6350661"/>
    </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="2018-10-01T14:08:44+02:00"/>
      <end value="2018-10-01T15:08:44+02:00"/>
    </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="urn:uuid:1523b52c-4a57-5b81-03d4-32fae9227a3f"/>
    </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="2018-10-01T14:08:44+02:00"/>
      <end value="2018-10-01T15:08:44+02:00"/>
    </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 "f19680c0-7e88-b970-819f-7b84321a8de3" 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: f19680c0-7e88-b970-819f-7b84321a8de3

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/22/2018 1:11:44 PM --> 1/22/2019 1:11:44 PM

provider:

organization:

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="f19680c0-7e88-b970-819f-7b84321a8de3"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:12.235Z"/>
  </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>: f19680c0-7e88-b970-819f-7b84321a8de3</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/22/2018 1:11:44 PM --&gt; 1/22/2019 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="4fed5b66-c2a4-be96-a8a4-a9b5384afac9"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2018-01-22T13:11:44+01:00"/>
    <end value="2019-01-22T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <service>
      <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension">
        <valueCoding>
          <system value="https://www.accessdata.fda.gov/scripts/cder/ndc"/>
          <code value="0624"/>
          <display value="Dummy"/>
        </valueCoding>
      </extension>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="430193006"/>
      </coding>
    </service>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="133.734"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="534.936"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="668.67"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="668.67"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="647.3520000000001"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "741417c2-0340-aa3d-ee52-c39b29d1c70e" 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: 741417c2-0340-aa3d-ee52-c39b29d1c70e

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/16/2017 1:11:44 PM --> 1/16/2018 1:11:44 PM

provider:

organization:

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="741417c2-0340-aa3d-ee52-c39b29d1c70e"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:11.204Z"/>
  </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>: 741417c2-0340-aa3d-ee52-c39b29d1c70e</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/16/2017 1:11:44 PM --&gt; 1/16/2018 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="a0480940-4e04-4e01-e51d-3ca0cba84feb"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2017-01-16T13:11:44+01:00"/>
    <end value="2018-01-16T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <service>
      <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension">
        <valueCoding>
          <system value="https://www.accessdata.fda.gov/scripts/cder/ndc"/>
          <code value="0624"/>
          <display value="Dummy"/>
        </valueCoding>
      </extension>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="430193006"/>
      </coding>
    </service>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="70.35000000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="281.40000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="351.75"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="351.75"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="393.81600000000003"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "0648e28c-c30f-cc2c-51d1-a59968879381" 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: 0648e28c-c30f-cc2c-51d1-a59968879381

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 10/27/2016 2:56:44 PM --> 10/27/2017 2:56:44 PM

created: 10/27/2016 2:56:44 PM

provider:

organization:

referral: #1

claim: urn:uuid:fbc6e7d1-1694-8519-774e-f776e2c5cf97

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="0648e28c-c30f-cc2c-51d1-a59968879381"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:10.235Z"/>
  </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>: 0648e28c-c30f-cc2c-51d1-a59968879381</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 10/27/2016 2:56:44 PM --&gt; 10/27/2017 2:56:44 PM</p>
      <p>
        <b>created</b>: 10/27/2016 2:56:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>referral</b>: #1</p>
      <p>
        <b>claim</b>:
        <a href="urn:uuid:fbc6e7d1-1694-8519-774e-f776e2c5cf97">urn:uuid:fbc6e7d1-1694-8519-774e-f776e2c5cf97</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
      </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="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="fbc6e7d1-1694-8519-774e-f776e2c5cf97"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <start value="2016-10-27T14:56:44+02:00"/>
    <end value="2017-10-27T14:56:44+02:00"/>
  </billablePeriod>
  <created value="2016-10-27T14:56:44+02:00"/>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <referral>
    <reference value="#1"/>
  </referral>
  <claim>
    <reference value="urn:uuid:fbc6e7d1-1694-8519-774e-f776e2c5cf97"/>
  </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:6a849f2b-81f1-227e-423c-7162c30a50d9"/>
    </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="2016-10-27T13:56:44+02:00"/>
      <end value="2016-10-27T14:56:44+02:00"/>
    </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="urn:uuid:8327470a-b1bf-aa96-b59c-db1956023fe4"/>
    </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="2016-10-27T13:56:44+02:00"/>
      <end value="2016-10-27T14:56:44+02:00"/>
    </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"/>
    <category>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd"/>
        <code value="1"/>
        <display value="Medical care"/>
      </coding>
    </category>
    <service>
      <coding>
        <system value="http://snomed.info/sct"/>
        <version value="v1"/>
        <code value="288086009"/>
      </coding>
    </service>
    <servicedPeriod>
      <start value="2016-10-27T13:56:44+02:00"/>
      <end value="2016-10-27T14:56:44+02:00"/>
    </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>
    <net>
      <value value="10683.10"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="2136.6200000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="8546.480000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="10683.10"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="10683.10"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <code value="A"/>
          <display value="Allowed"/>
        </coding>
      </reason>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="8546.480000000001"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "f9f30cdc-e964-1ede-57c1-82e1bc9408e8" 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: f9f30cdc-e964-1ede-57c1-82e1bc9408e8

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/11/2016 1:11:44 PM --> 1/11/2017 1:11:44 PM

provider:

organization:

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="f9f30cdc-e964-1ede-57c1-82e1bc9408e8"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:09.829Z"/>
  </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>: f9f30cdc-e964-1ede-57c1-82e1bc9408e8</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/11/2016 1:11:44 PM --&gt; 1/11/2017 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="cc5045e2-7d01-565f-3b82-59f749feb86d"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2016-01-11T13:11:44+01:00"/>
    <end value="2017-01-11T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="112.41600000000001"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "fbdcb2de-07b0-7c25-5667-3c0dd56cc059" 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: fbdcb2de-07b0-7c25-5667-3c0dd56cc059

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/5/2015 1:11:44 PM --> 1/5/2016 1:11:44 PM

provider:

organization:

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="fbdcb2de-07b0-7c25-5667-3c0dd56cc059"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:08.704Z"/>
  </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>: fbdcb2de-07b0-7c25-5667-3c0dd56cc059</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/5/2015 1:11:44 PM --&gt; 1/5/2016 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="fb86dc32-429a-d312-a59d-d814544e5d6c"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2015-01-05T13:11:44+01:00"/>
    <end value="2016-01-05T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="224.83200000000002"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "6053e748-4134-d7c0-d11e-cc8be3f7ef40" 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: 6053e748-4134-d7c0-d11e-cc8be3f7ef40

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 1/11/2014 1:11:44 PM --> 1/11/2015 1:11:44 PM

provider:

organization:

totalCost: 77.49 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="6053e748-4134-d7c0-d11e-cc8be3f7ef40"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:07.516Z"/>
  </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>: 6053e748-4134-d7c0-d11e-cc8be3f7ef40</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 1/11/2014 1:11:44 PM --&gt; 1/11/2015 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="25085ca4-5474-d458-2d2f-69f0cc6511e0"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2014-01-11T13:11:44+01:00"/>
    <end value="2015-01-11T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="77.49"/>
    <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 "f355855d-cdd0-ab22-babb-84f8b1fe840f" 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: f355855d-cdd0-ab22-babb-84f8b1fe840f

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 12/30/2013 1:11:44 PM --> 12/30/2014 1:11:44 PM

provider:

organization:

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="f355855d-cdd0-ab22-babb-84f8b1fe840f"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:07.266Z"/>
  </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>: f355855d-cdd0-ab22-babb-84f8b1fe840f</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 12/30/2013 1:11:44 PM --&gt; 12/30/2014 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </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>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="93821995-1f4e-e089-c61f-bbcb0b9755d8"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2013-12-30T13:11:44+01:00"/>
    <end value="2014-12-30T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="b08bcd93-e940-3a82-a7fe-2d627fe127ac"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="189f595a-277f-3a7f-93fc-f34a642885fc"/>
    </identifier>
  </organization>
  <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>
  <insurance>
    <coverage>
      <reference value="#coverage"/>
    </coverage>
  </insurance>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="3"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="4"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="5"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="22"/>
        <display value="Outpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt"/>
          <display value="Line Beneficiary Coinsurance Amount"/>
        </coding>
      </category>
      <amount>
        <value value="28.104000000000003"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt"/>
          <display value="Line Provider Payment Amount"/>
        </coding>
      </category>
      <amount>
        <value value="112.41600000000001"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt"/>
          <display value="Line Submitted Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt"/>
          <display value="Line Allowed Charge Amount"/>
        </coding>
      </category>
      <amount>
        <value value="140.52"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt"/>
          <display value="Line Beneficiary Part B Deductible Amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="https://bluebutton.cms.gov/resources/codesystem/adjudication"/>
          <code value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd"/>
          <display value="Line Processing Indicator Code"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <totalCost>
    <value value="129.16"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <payment>
    <amount>
      <value value="449.66400000000004"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
  </payment>
</ExplanationOfBenefit>

ExplanationOfBenefit "9baf773f-92b5-7946-4f59-122a90c2c283" 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: 9baf773f-92b5-7946-4f59-122a90c2c283

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 12/12/2013 1:11:44 PM --> 12/12/2014 1:11:44 PM

provider:

organization:

totalCost: 77.49 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="9baf773f-92b5-7946-4f59-122a90c2c283"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:05.500Z"/>
  </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>: 9baf773f-92b5-7946-4f59-122a90c2c283</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 12/12/2013 1:11:44 PM --&gt; 12/12/2014 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="0017d571-f521-a762-eaa3-8a5ce64a59ff"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2013-12-12T13:11:44+01:00"/>
    <end value="2014-12-12T13:11:44+01:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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:16201792-8384-c776-1249-244d43c3c02f"/>
    </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>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="77.49"/>
    <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 "515189ab-96ed-d633-277a-ed7feb590462" 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: 515189ab-96ed-d633-277a-ed7feb590462

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 7/24/2013 2:11:44 PM --> 7/24/2014 2:11:44 PM

provider:

organization:

totalCost: 77.49 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="515189ab-96ed-d633-277a-ed7feb590462"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:05.079Z"/>
  </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>: 515189ab-96ed-d633-277a-ed7feb590462</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 7/24/2013 2:11:44 PM --&gt; 7/24/2014 2:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization</b>: </p>
      <p>
        <b>totalCost</b>: 77.49 USD
        <span style="background: LightGoldenRodYellow ">(Details: urn:iso:std:iso:4217 code USD := "USD")</span>
      </p>
    </div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage"/>
      <type>
        <text value="Blue Cross Blue Shield"/>
      </type>
    </Coverage>
  </contained>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension">
    <valueCoding>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd"/>
      <code value="N"/>
      <display value="All other reasons for non-payment"/>
    </valueCoding>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension">
    <valueMoney>
      <value value="0.0"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </valueMoney>
  </extension>
  <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension">
    <valueIdentifier>
      <system value="https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"/>
      <value value="002000"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://bluebutton.cms.gov/resources/variables/clm_id"/>
    <value value="2ae11a4e-fbac-67da-cb0d-58c96119ce49"/>
  </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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7"/>
  </patient>
  <billablePeriod>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension">
      <valueCoding>
        <system value="https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd"/>
        <code value="3"/>
        <display value="Final Bill"/>
      </valueCoding>
    </extension>
    <start value="2013-07-24T14:11:44+02:00"/>
    <end value="2014-07-24T14:11:44+02:00"/>
  </billablePeriod>
  <provider>
    <identifier>
      <value value="3dbd3a95-b1f6-34aa-9ce7-64c2f1ad2ea2"/>
    </identifier>
  </provider>
  <organization>
    <identifier>
      <value value="4bdaa4c2-c664-3089-aee2-7137abbad27f"/>
    </identifier>
  </organization>
  <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:d35c058c-a220-146d-743f-74ff243bf9d3"/>
    </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>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="1"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <item>
    <extension url="https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension">
      <valueQuantity>
        <value value="0"/>
      </valueQuantity>
    </extension>
    <sequence value="2"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
  </item>
  <totalCost>
    <value value="77.49"/>
    <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 "56cc029d-ffd0-d2f8-bac1-b3859e072d67" 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: 56cc029d-ffd0-d2f8-bac1-b3859e072d67

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: urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7

billablePeriod: 12/24/2012 1:11:44 PM --> 12/24/2013 1:11:44 PM

provider:

organization:

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="56cc029d-ffd0-d2f8-bac1-b3859e072d67"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2021-01-15T16:21:04.641Z"/>
  </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>: 56cc029d-ffd0-d2f8-bac1-b3859e072d67</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="urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7">urn:uuid:2fd1e877-04eb-b820-619f-06f14e918be7</a>
      </p>
      <p>
        <b>billablePeriod</b>: 12/24/2012 1:11:44 PM --&gt; 12/24/2013 1:11:44 PM</p>
      <p>
        <b>provider</b>: </p>
      <p>
        <b>organization