FHIR © HL7.org  |  Server Home  |  Health Intersections FHIR Server v1.0.183  |  FHIR Version 3.0.1  | User: ANONYMOUS (Unknown)  

History Record

XML or JSON representation

Links: First Previous Next Last  (51 found). Search: http://test.fhir.org/r3/ExplanationOfBenefit/_history?&_prior=2017-10-20T05:18:38Z&_format=text/xhtml&history-id=c8728151-b7a2-4728-9f2e-ea186c874c 

SQL (for debugging): Insert into SearchEntries Select 26992, Ids.ResourceKey, Versions.ResourceVersionKey, RIGHT ('0000000000000'+CAST(Versions.ResourceVersionKey AS VARCHAR(14)),14) as sort, null, null from Versions, Ids, Sessions where Ids.ResourceTypeKey = 48 and Versions.ResourceKey = Ids.ResourceKey and Versions.SessionKey = Sessions.SessionKey order by ResourceVersionKey DESC

ExplanationOfBenefit "14" Version "1"

Created by ANONYMOUS (Unknown) at 10/19/2017 7:10:27 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

d60W4LAbMZ0PiRPklf59Yg==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="14"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-10-19T07:10:27Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="de-AT"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">d60W4LAbMZ0PiRPklf59Yg==</div>
  </text>
  <identifier>
    <use value="secondary"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/identifier-type"/>
        <code value="PLAC"/>
        <display value="Placer Identifier"/>
        <userSelected value="true"/>
      </coding>
      <text value="uAu1BGqFiPKyl0gzlnAe6Q=="/>
    </type>
    <system value="http://projectcrucible.org/Hflxx/NpskqtCsHmEBIRwg=="/>
    <value value="u3yK38IdAGdVxHnhICOVug=="/>
    <period>
      <start value="2017-10-19T03:10:27.536Z"/>
      <end value="2017-10-19T03:10:27.536Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/oqaZ/9O9jUMMPk8jv4b3ag=="/>
        <value value="vph2YJvZmF6ZDVy4+KeC7g=="/>
      </identifier>
      <display value="Organization +Da+bGUH3/z6cUEcJGCitQ=="/>
    </assigner>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="professional"/>
      <display value="Professional"/>
      <userSelected value="true"/>
    </coding>
    <text value="Qi9a5ImR8P3mxYYxd0bGKA=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="ortho"/>
      <display value="Orthodontic Claim"/>
      <userSelected value="false"/>
    </coding>
    <text value="3rPuw7bN2vRt+6pjJFy1ag=="/>
  </subType>
  <patient>
    <identifier>
      <use value="official"/>
      <type>
        <text value="L+5iEAiIY7ti4vImjyBMQQ=="/>
      </type>
      <system value="http://projectcrucible.org/ESZq29oatcPNpqLzJO322Q=="/>
      <value value="Vr3UehET6pl7P9Tsnrx4kw=="/>
      <period>
        <start value="2017-10-19T03:10:27.540Z"/>
        <end value="2017-10-19T03:10:27.540Z"/>
      </period>
      <assigner>
        <display value="Organization VXaNWTFymnku5PxwvKfkCA=="/>
      </assigner>
    </identifier>
    <display value="Patient qEDzlPMcE3vuTKfr75dK0w=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-19T03:10:27.541Z"/>
    <end value="2017-10-19T03:10:27.541Z"/>
  </billablePeriod>
  <created value="2017-10-19T03:10:27.541Z"/>
  <enterer>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="etp6uG1nJa8i7B9XWxWFRg=="/>
      </type>
      <system value="http://projectcrucible.org/fUgnWUMBwIHyT/Swd/9s9w=="/>
      <value value="d+Ng2QnatPVeWDF5zyS/RQ=="/>
      <period>
        <start value="2017-10-19T03:10:27.541Z"/>
        <end value="2017-10-19T03:10:27.541Z"/>
      </period>
      <assigner>
        <display value="Organization dGV5/OeC/xDd4Iny/bZggg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner 1MpfdNPN8l3E5RCsKwF0mQ=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="FBexRfkW7pft5EiuN0uFfA=="/>
      </type>
      <system value="http://projectcrucible.org/F9NKOXppg7V8LFckSjThJw=="/>
      <value value="K6rsErAD+sZW7XZaTZIbqA=="/>
      <period>
        <start value="2017-10-19T03:10:27.542Z"/>
        <end value="2017-10-19T03:10:27.542Z"/>
      </period>
      <assigner>
        <display value="Organization S39+9c25er5C41kMIRVGdQ=="/>
      </assigner>
    </identifier>
    <display value="Organization /8l5oI9zz8UZR7rGGqRiFQ=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="aiu2gqw84JyOZQIeeqUcJg=="/>
      </type>
      <system value="http://projectcrucible.org/UD0gPSQny7w8ZI9rOO+eJg=="/>
      <value value="TBrW5hz8B85pprhjuTEc1w=="/>
      <period>
        <start value="2017-10-19T03:10:27.543Z"/>
        <end value="2017-10-19T03:10:27.543Z"/>
      </period>
      <assigner>
        <display value="Organization TZSZAmFSpxv/bgly5fa2/Q=="/>
      </assigner>
    </identifier>
    <display value="Practitioner xGhDzntzifWkZw1iAIqRHg=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="i1aE6TGoryai7NvNPT3HXw=="/>
      </type>
      <system value="http://projectcrucible.org/Ls4TyfSCfJdEcyTjWd3Nyg=="/>
      <value value="wItxB6hxhYyMQNQSzXVWLg=="/>
      <period>
        <start value="2017-10-19T03:10:27.543Z"/>
        <end value="2017-10-19T03:10:27.543Z"/>
      </period>
      <assigner>
        <display value="Organization 7V+xDpqdnldnKlNWkZrwpQ=="/>
      </assigner>
    </identifier>
    <display value="Organization 6wVCsFRmdlPakdV48Cwa1A=="/>
  </organization>
  <referral>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="p+lVIYDMvwxau9q9B3fX7A=="/>
      </type>
      <system value="http://projectcrucible.org/SSTC7vF7UVr628JMu2aUWg=="/>
      <value value="4l5KmBbzBtbCE4spUrfmUQ=="/>
      <period>
        <start value="2017-10-19T03:10:27.544Z"/>
        <end value="2017-10-19T03:10:27.544Z"/>
      </period>
      <assigner>
        <display value="Organization tkKFj1PKyu8X6iGQcA58Bg=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest Ivq1emGOR7xUnArzPeaEDg=="/>
  </referral>
  <facility>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="ONcdk0gUD6V6ojZ7YDn3rw=="/>
      </type>
      <system value="http://projectcrucible.org/oJBT/VGN17+BMoMJOMHkQA=="/>
      <value value="9TsAatSL/Lh0K1f21BOH2Q=="/>
      <period>
        <start value="2017-10-19T03:10:27.544Z"/>
        <end value="2017-10-19T03:10:27.544Z"/>
      </period>
      <assigner>
        <display value="Organization JjQZGC/B+1LtgrZqaZ68xA=="/>
      </assigner>
    </identifier>
    <display value="Location RY4cQIqX5USIS/UEFU7e7A=="/>
  </facility>
  <claim>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="j3kZ0hNy16+kBIlm93tdpQ=="/>
      </type>
      <system value="http://projectcrucible.org/LoLJSvS+GvBcI1oJDsHY6Q=="/>
      <value value="dfRq4KOIca+dyWmNBS1Y3Q=="/>
      <period>
        <start value="2017-10-19T03:10:27.545Z"/>
        <end value="2017-10-19T03:10:27.545Z"/>
      </period>
      <assigner>
        <display value="Organization 5DRV9Zib9pTqtQdRI4tpnA=="/>
      </assigner>
    </identifier>
    <display value="Claim uPfzspqxlD1d+9HugL2pvw=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="Rge/Z6NI3DKRaO5p7pPCzw=="/>
      </type>
      <system value="http://projectcrucible.org/HJwMEiY/mlMF6Uhp/7e/oA=="/>
      <value value="gSAqWGbnUubEiqhYsruKjw=="/>
      <period>
        <start value="2017-10-19T03:10:27.545Z"/>
        <end value="2017-10-19T03:10:27.545Z"/>
      </period>
      <assigner>
        <display value="Organization to7U7x1SFWimFh62xtCDAQ=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse kb06ea7cfS6t5M659SVk8A=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="partial"/>
      <display value="Partial Processing"/>
      <userSelected value="false"/>
    </coding>
    <text value="rGVrS+xtky4mvMkAgxVdMg=="/>
  </outcome>
  <disposition value="PKfvkVQlVHfIZzai8007pw=="/>
  <related>
    <claim>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/By0uoMMa/+W/LWS1HktJGg=="/>
        <value value="fZu4hhcHx7oIH0GbCn1ivg=="/>
      </identifier>
      <display value="Claim A41qeU112f+Bmor3EkPQSw=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="XZ8O5vhPvYSk3sTsfuD64g=="/>
    </relationship>
    <reference>
      <use value="temp"/>
      <type>
        <text value="X1N/35RitT8mh4RYJfL8sg=="/>
      </type>
      <system value="http://projectcrucible.org/SR0cG59YWbAlBgdwvFlIzg=="/>
      <value value="NXUHJqqCtAoGh1kFMqqUKQ=="/>
      <period>
        <start value="2017-10-19T03:10:27.548Z"/>
        <end value="2017-10-19T03:10:27.548Z"/>
      </period>
      <assigner>
        <display value="Organization XaD16zaafaOCed/15HEKCw=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="vLUzm2LaeBSiKh255IgYQw=="/>
      </type>
      <system value="http://projectcrucible.org/pqdOvRAOxqzLhof0x45cEg=="/>
      <value value="9zifDGaHzj7VChym+YqTow=="/>
      <period>
        <start value="2017-10-19T03:10:27.549Z"/>
        <end value="2017-10-19T03:10:27.549Z"/>
      </period>
      <assigner>
        <display value="Organization Dqt2rClSEAI67yzPSFesWg=="/>
      </assigner>
    </identifier>
    <display value="VisionPrescription X1zgorNcpVvWZ6zyRzRcDg=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="HRCZoyCz3nu7RsOa/c8QZw=="/>
      </type>
      <system value="http://projectcrucible.org/2Bk2j7g2/g3NYvmfwXOlhQ=="/>
      <value value="nd+TjQWGsJOkPz22ImdVjA=="/>
      <period>
        <start value="2017-10-19T03:10:27.549Z"/>
        <end value="2017-10-19T03:10:27.549Z"/>
      </period>
      <assigner>
        <display value="Organization oCIgirdPnEIOBOmTZKCPnA=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest tVi9So/WDrnPO2y1YvgL2w=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="Bu/IJW7Qej7FKISm6eEAjQ=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="practitioner"/>
        <display value="Practitioner"/>
        <userSelected value="true"/>
      </coding>
      <text value="4GRz2ogpyjf82g/uH4n7Iw=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/lysOJJLGxrcCgrn/+g7t5g=="/>
        <value value="/nD4+uwN/Dxzlwk0ooPuxA=="/>
      </identifier>
      <display value="RelatedPerson po4y/II0x7nfL4nh1HdzdA=="/>
    </party>
  </payee>
  <information>
    <sequence value="71"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="onset"/>
        <display value="Onset"/>
        <userSelected value="false"/>
      </coding>
      <text value="sAVhB92uLpl1sGrOZU0QYw=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="student"/>
        <display value="Student (Fulltime)"/>
        <userSelected value="false"/>
      </coding>
      <text value="ARZsTy2wvTotUGDHJBfNAw=="/>
    </code>
    <timingPeriod>
      <start value="2017-10-19T03:10:27.555Z"/>
      <end value="2017-10-19T03:10:27.555Z"/>
    </timingPeriod>
    <valueAttachment>
      <contentType value="application/EmergencyCallData.SubscriberInfo+xml"/>
      <language value="es"/>
      <url value="http://projectcrucible.org/UrzVIXv2xT3GsAtWPUkFjw=="/>
      <size value="23"/>
      <hash value="jnEUQK1zZr5MXCFswefc+g=="/>
      <title value="IP5zeBP7x+dx22ylFf0mBw=="/>
      <creation value="2017-10-19T03:10:27.556Z"/>
    </valueAttachment>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="c"/>
      <display value="C"/>
      <userSelected value="false"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="70"/>
    <provider>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/jaeBNGHLCMy2TrFJeHt0VQ=="/>
        <value value="BtvnVHh68O4dYVKGu6s2hQ=="/>
      </identifier>
      <display value="Practitioner FQIIcCRpz6jKbFML9WbLzA=="/>
    </provider>
    <responsible value="false"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="supervisor"/>
        <display value="Supervising Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="oFz/V+UsUFDerIf3v7cWRw=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="false"/>
      </coding>
      <text value="XHL2JVzg6mezJT+dpAI2rg=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="74"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/xSrZKyGsAyga7ilmZpOPnQ=="/>
        <code value="ojKDF4FUNEA4aeVFYLnFcA=="/>
        <display value="ZD7VdgG2MuELnZfkkRi6xg=="/>
        <userSelected value="true"/>
      </coding>
      <text value="/hPpYrHTgLU22ufGxNRpDA=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="clinical"/>
        <display value="Clinical Diagnosis"/>
        <userSelected value="false"/>
      </coding>
      <text value="cE7XzE0fgVizrkZHk5MHXg=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="300"/>
        <display value="Tooth abcess"/>
        <userSelected value="true"/>
      </coding>
      <text value="+1PloOHwC5Ss7Dgb5wRovg=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="83"/>
    <date value="2017-10-19T03:10:27.563Z"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
        <code value="123003"/>
        <display value="PROC-3"/>
        <userSelected value="false"/>
      </coding>
      <text value="Fq4KMXWIYKg3sX0YFem88g=="/>
    </procedureCodeableConcept>
  </procedure>
  <precedence value="1"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/1fEQ/FSwv13LGKjNnhb4KA=="/>
        <value value="47eOv0whOhPigpgGEfdqGA=="/>
      </identifier>
      <display value="Coverage FsooQR+aQHSG5xQiaaP1Ig=="/>
    </coverage>
    <preAuthRef value="oXoN4yLEvJriAtneaq2ALQ=="/>
  </insurance>
  <accident>
    <date value="2017-10-19"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="SPT"/>
        <display value="Sporting Accident"/>
        <userSelected value="true"/>
      </coding>
      <text value="D43A/QVaNZSLIA+c2rhaJQ=="/>
    </type>
    <locationReference>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/NnCDtoIbmxyfZ4UIUbdvIA=="/>
        <value value="Gw3EsKEwMlJ2X/lsCbBqlw=="/>
      </identifier>
      <display value="Location HVk+M+qPDxNpg7b8RLxlxg=="/>
    </locationReference>
  </accident>
  <employmentImpacted>
    <start value="2017-10-19T03:10:27.567Z"/>
    <end value="2017-10-19T03:10:27.567Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-19T03:10:27.567Z"/>
    <end value="2017-10-19T03:10:27.567Z"/>
  </hospitalization>
  <item>
    <sequence value="97"/>
    <careTeamLinkId value="98"/>
    <diagnosisLinkId value="59"/>
    <procedureLinkId value="20"/>
    <informationLinkId value="49"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0010"/>
        <display value="Vision Clinic"/>
        <userSelected value="true"/>
      </coding>
      <text value="lQ+xqHnCM4VL5DBzz4qklA=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="24"/>
        <display value="Periodontics"/>
        <userSelected value="false"/>
      </coding>
      <text value="W6MOFFgKKrHc6wLjSROJwA=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1102"/>
        <display value="Exam, comp, mixed"/>
        <userSelected value="false"/>
      </coding>
      <text value="P2IBLOqeVI0/QSvqjDCJLw=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="rooh"/>
        <display value="Rush or Outside of office hours"/>
        <userSelected value="false"/>
      </coding>
      <text value="b1XA1gV133dPcR9nul/M4w=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="as"/>
        <display value="Child Asthma"/>
        <userSelected value="true"/>
      </coding>
      <text value="pvggLjlZv+sFvEUAgrMW9w=="/>
    </programCode>
    <servicedDate value="2017-10-19"/>
    <locationAddress>
      <use value="home"/>
      <type value="postal"/>
      <text value="Qf6J8t6ya/nNuGgqdIrTXA=="/>
      <line value="k8yoMo/o2ukkTpYEbJcrYw=="/>
      <city value="OCOtrWaj2+VWOqW3CDxNHQ=="/>
      <district value="xTka/wKsp2YLWTMf4zdL4w=="/>
      <state value="FIHsRFeut/spmVSHgWre0Q=="/>
      <postalCode value="UsQu2I0YBP2fWqrxqiJyMA=="/>
      <country value="XyZDGfVpSvB8XV6eT0qSmA=="/>
      <period>
        <start value="2017-10-19T03:10:27.573Z"/>
        <end value="2017-10-19T03:10:27.573Z"/>
      </period>
    </locationAddress>
    <quantity>
      <value value="0.4454239018908738"/>
      <unit value="SwHz3RmqzMbR1vXaJfBogA=="/>
      <system value="http://projectcrucible.org/APT55+kWt0piaAIxOfFO8w=="/>
      <code value="U9Tc09iVxQ4VuFPrteAC3g=="/>
    </quantity>
    <unitPrice>
      <value value="0.8102966799483821"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.5695641964806881"/>
    <net>
      <value value="0.05766719542583343"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org//BqBIOGDegqMfQ45fvYVeA=="/>
        <value value="K64EbBbM/eg7XNCbxPO3WQ=="/>
      </identifier>
      <display value="Device M0SxLPgIvm7bCbUmpOZd7g=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="36"/>
        <display value="36"/>
        <userSelected value="false"/>
      </coding>
      <text value="yHxLKv9vDih1V+th2g3h8g=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="D"/>
        <display value="Distal"/>
        <userSelected value="true"/>
      </coding>
      <text value="5ltbLnzPkLD66766fvBtCg=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/OcFbnu5FRmOy7o2Z46e99w=="/>
        <value value="UtFOVOLmiNKAE9MGNpxxbw=="/>
      </identifier>
      <display value="Encounter 8XBR35e/Ww7v1rujkYTHpA=="/>
    </encounter>
    <noteNumber value="4"/>
    <adjudication>
      <category>
        <text value="4MNw7ISYUr9ZmwGp9YpBiw=="/>
      </category>
      <reason>
        <text value="oC3+tzMYDzwCYVGyDKarqg=="/>
      </reason>
      <amount>
        <value value="0.4174827278374079"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.8212982632855567"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="14"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0420"/>
        <display value="Physical Therapy"/>
        <userSelected value="true"/>
      </coding>
      <text value="Q84+DlAP2UNK4GYHKDTfvw=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="4"/>
        <display value="Diagnostic XRay"/>
        <userSelected value="false"/>
      </coding>
      <text value="hxvnZhKHJj7OGixLh76Iag=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="11102"/>
        <display value="Polishing, 2 unit"/>
        <userSelected value="true"/>
      </coding>
      <text value="FvWWbB7jRBcrfNxS4LNrCA=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="e"/>
        <display value="Implant or associated with an implant"/>
        <userSelected value="false"/>
      </coding>
      <text value="myPZOjlPBru4Qylf+qf5bw=="/>
    </modifier>
    <fee>
      <value value="0.43292336450953284"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="91"/>
    <adjudication>
      <category>
        <text value="TYFEDlKMIpx2If6ZNVOkBg=="/>
      </category>
      <reason>
        <text value="DCohBf2OGNMc7LD/pZ/8ug=="/>
      </reason>
      <amount>
        <value value="0.21592650571065097"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.007734346609860943"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.29773990572506526"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.5120009835741566"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.33062494942195075"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="SCE/lT+lttnSN0m8vR+fXg=="/>
    </type>
    <adjustment>
      <value value="0.45097014685035497"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a002"/>
        <display value="Prior Overpayment"/>
        <userSelected value="false"/>
      </coding>
      <text value="GCfEf1SoUXIkJJ8f12zJkQ=="/>
    </adjustmentReason>
    <date value="2017-10-19"/>
    <amount>
      <value value="0.07101415403911271"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="QiHZ1WBuPbIdnkK4CaqSnw=="/>
      </type>
      <system value="http://projectcrucible.org/drnZlBZelGGt+as1AWM27w=="/>
      <value value="wgU3lhpoDPOQVwAZLjX0Gg=="/>
      <period>
        <start value="2017-10-19T03:10:27.589Z"/>
        <end value="2017-10-19T03:10:27.589Z"/>
      </period>
      <assigner>
        <display value="Organization njbOwTcg6tjPDLEyS+qWhQ=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="1"/>
      <display value="Form #1"/>
      <userSelected value="false"/>
    </coding>
    <text value="4px3+Botj6RhsCuNWY3dUQ=="/>
  </form>
  <processNote>
    <number value="39"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="display"/>
        <display value="Display"/>
        <userSelected value="true"/>
      </coding>
      <text value="lt5hwLy/xHNfFEqipG0ikA=="/>
    </type>
    <text value="DpDksc+PYHmNuHkZWx3mQg=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="bn"/>
        <display value="Bengalsk"/>
        <userSelected value="true"/>
      </coding>
      <text value="6nL4XcGjTdlElkCqe7ssMQ=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="pharmacy"/>
        <display value="Pharmacy Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="iBIIZcHUcVSU1r/ehr4f4w=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="76"/>
        <display value="Renal Dialysis"/>
        <userSelected value="false"/>
      </coding>
      <text value="At6iHYkw5shoddnUz+O9eg=="/>
    </subCategory>
    <excluded value="true"/>
    <name value="sD4IZqARHnSLN1z1Z303Dg=="/>
    <description value="LQ8o21G9O3lCl8wPIpbumw=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="in"/>
        <display value="In Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="c9wylo25Cj6sPpGGp3ZYxQ=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="family"/>
        <display value="Family"/>
        <userSelected value="true"/>
      </coding>
      <text value="FfslRUOrHxu4QhW9F8hA2Q=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="annual"/>
        <display value="Annual"/>
        <userSelected value="true"/>
      </coding>
      <text value="ajv3MEMFxYAv2UbX+svmXA=="/>
    </term>
    <financial>
      <type>
        <text value="/R/KZj7c6iebidEBDdBP2A=="/>
      </type>
      <allowedMoney>
        <value value="0.8976939806035501"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </allowedMoney>
      <usedUnsignedInt value="11"/>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

ExplanationOfBenefit "13" Version "1"

Created by ANONYMOUS (Unknown) at 10/19/2017 6:41:35 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

SYzV/OFTz82EpzoGELpW+g==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="13"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-10-19T06:41:35Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="en-SG"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">SYzV/OFTz82EpzoGELpW+g==</div>
  </text>
  <identifier>
    <use value="secondary"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v2/0203"/>
        <code value="PRN"/>
        <display value="Provider number"/>
        <userSelected value="true"/>
      </coding>
      <text value="HmIXe1GJnm0wlHXQFa3HOg=="/>
    </type>
    <system value="http://projectcrucible.org/mSM4srgrdExZIs3cRrwKUA=="/>
    <value value="brFRuF7o9gM1xP2zTIJshQ=="/>
    <period>
      <start value="2017-10-19T02:41:35.033Z"/>
      <end value="2017-10-19T02:41:35.033Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/UuZbKDFG+pAbixdxWmu3Nw=="/>
        <value value="jANSXBI6xwAuSK8CpyFGlw=="/>
      </identifier>
      <display value="Organization PNkREO0anO+VrlGrCbdiqA=="/>
    </assigner>
  </identifier>
  <status value="entered-in-error"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="oral"/>
      <display value="Oral"/>
      <userSelected value="false"/>
    </coding>
    <text value="CVj4hg95LEjOFeiTRp2E2Q=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="emergency"/>
      <display value="Emergency Claim"/>
      <userSelected value="false"/>
    </coding>
    <text value="01slAS4xTKHxEUIyuDwfGw=="/>
  </subType>
  <patient>
    <identifier>
      <use value="official"/>
      <type>
        <text value="ZwaxwNnU12HG3fT1iUIPFA=="/>
      </type>
      <system value="http://projectcrucible.org/YWX1iATXNnC3rcKPV0r5Sg=="/>
      <value value="ANuBfff/GWXXudYOm/WETw=="/>
      <period>
        <start value="2017-10-19T02:41:35.036Z"/>
        <end value="2017-10-19T02:41:35.036Z"/>
      </period>
      <assigner>
        <display value="Organization dKGKwCx5EoZPR7WqIxDH4g=="/>
      </assigner>
    </identifier>
    <display value="Patient pFv2z+DaviAiAL+x+fViCw=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-19T02:41:35.037Z"/>
    <end value="2017-10-19T02:41:35.037Z"/>
  </billablePeriod>
  <created value="2017-10-19T02:41:35.037Z"/>
  <enterer>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="A16uIlvp/5GyGhcWgxCBYw=="/>
      </type>
      <system value="http://projectcrucible.org/LOmC0IjVx0SSLNNt402JXQ=="/>
      <value value="iUgI9xTlb/3dgH+Lq9LIzQ=="/>
      <period>
        <start value="2017-10-19T02:41:35.037Z"/>
        <end value="2017-10-19T02:41:35.037Z"/>
      </period>
      <assigner>
        <display value="Organization vGz6hEri7wEQQcnijuKNtg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner 9meFqI5LqUzGx65gkI+mTQ=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="NunsBme1StwDAflgxpMQMQ=="/>
      </type>
      <system value="http://projectcrucible.org/5TNh7WjL2vJUt7I0cdknSw=="/>
      <value value="5Cs9YtnF0bN6Wdg0KZqWZg=="/>
      <period>
        <start value="2017-10-19T02:41:35.038Z"/>
        <end value="2017-10-19T02:41:35.038Z"/>
      </period>
      <assigner>
        <display value="Organization SvdBgsVorivs0nfQUjPWoA=="/>
      </assigner>
    </identifier>
    <display value="Organization okSIgxH0EAzDUc8SsfM6XA=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="jj2n2kW5KxxvOer/Jp5mCA=="/>
      </type>
      <system value="http://projectcrucible.org/QPLRofNMpIMg35F0DgWxig=="/>
      <value value="+NcLvQ11fxzBRv6diSGU5A=="/>
      <period>
        <start value="2017-10-19T02:41:35.038Z"/>
        <end value="2017-10-19T02:41:35.038Z"/>
      </period>
      <assigner>
        <display value="Organization sa9PA6KOZaC195ygBPmqRQ=="/>
      </assigner>
    </identifier>
    <display value="Practitioner pYWMq6vJC+E0weDP6O59JQ=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="R7CO2uiDYhuJN4caCiJbGw=="/>
      </type>
      <system value="http://projectcrucible.org/SzI97LcIbJrxnjkDDI+2dA=="/>
      <value value="BRkvMdEZue0QPvoERfeUDA=="/>
      <period>
        <start value="2017-10-19T02:41:35.039Z"/>
        <end value="2017-10-19T02:41:35.039Z"/>
      </period>
      <assigner>
        <display value="Organization ZhR9uUEO9Qwj3i6LXZy7Xg=="/>
      </assigner>
    </identifier>
    <display value="Organization HNYcsefputNJlFKKetjBIA=="/>
  </organization>
  <referral>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="iJ6QYfbibwcgFmLduHL0Mw=="/>
      </type>
      <system value="http://projectcrucible.org/+vfc22NnsJyXODaQxbZKNQ=="/>
      <value value="z0nLP4hOrboBFv3xd7L4kg=="/>
      <period>
        <start value="2017-10-19T02:41:35.040Z"/>
        <end value="2017-10-19T02:41:35.040Z"/>
      </period>
      <assigner>
        <display value="Organization dtNYCDFWOzgbF5U1V1cGeQ=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest uD2DKvgbx/2jBlgKE0tB1g=="/>
  </referral>
  <facility>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="RhNozk33m24PAulJpOHxeA=="/>
      </type>
      <system value="http://projectcrucible.org/WzaDP4MfYGk1dWbvH00e8A=="/>
      <value value="nlJ7cwP1M85uuePBO2k/lQ=="/>
      <period>
        <start value="2017-10-19T02:41:35.041Z"/>
        <end value="2017-10-19T02:41:35.041Z"/>
      </period>
      <assigner>
        <display value="Organization eyx55THJGujbvl6fbRCT2w=="/>
      </assigner>
    </identifier>
    <display value="Location dSO+Dg0nvjImWoyiEMoBLQ=="/>
  </facility>
  <claim>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="hztyYOTmlvzqbzN1GTsEAw=="/>
      </type>
      <system value="http://projectcrucible.org/U8lwWPHSghbjJK6LmboDbQ=="/>
      <value value="8UQ92DF7XhAfcdAf6QLDwA=="/>
      <period>
        <start value="2017-10-19T02:41:35.042Z"/>
        <end value="2017-10-19T02:41:35.042Z"/>
      </period>
      <assigner>
        <display value="Organization xjdw1fH9kvrUzSIHtA5I/w=="/>
      </assigner>
    </identifier>
    <display value="Claim gHvq7UzFiJUHq8HYkWKU2Q=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="7LSbjm6ysrviSVwBcw22aw=="/>
      </type>
      <system value="http://projectcrucible.org/g7q2JxOQMXPPdd71jTL90g=="/>
      <value value="fxyrb2C65Cf4gnSZRD0Q8g=="/>
      <period>
        <start value="2017-10-19T02:41:35.042Z"/>
        <end value="2017-10-19T02:41:35.042Z"/>
      </period>
      <assigner>
        <display value="Organization 9ww1a1dz9H2TRHvJIHRXeA=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse 3xNdKmdlxshZ+rkBd+vi9g=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
      <display value="Processing Complete"/>
      <userSelected value="false"/>
    </coding>
    <text value="pZLqf0s0gAPXYiAvvo+y8g=="/>
  </outcome>
  <disposition value="YcIYowEaEYWKURd+TGTrAQ=="/>
  <related>
    <claim>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/UMux73emAcysLNafne3A/Q=="/>
        <value value="VVAvQUKq0WVnGYli+nHP5Q=="/>
      </identifier>
      <display value="Claim 7MVylkAzPG+zPhVE1pGq4w=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="nN8bkh7rCGmbhFFXsO5iYw=="/>
    </relationship>
    <reference>
      <use value="usual"/>
      <type>
        <text value="fLZQLJ17xAf0px1MnSA/+g=="/>
      </type>
      <system value="http://projectcrucible.org/biYeXNQpSQHmJUxmBtfQvg=="/>
      <value value="1AzPHLbpjCF8pZ+evnPBfw=="/>
      <period>
        <start value="2017-10-19T02:41:35.047Z"/>
        <end value="2017-10-19T02:41:35.047Z"/>
      </period>
      <assigner>
        <display value="Organization 3HQ+Ua25DeMQXERzIOucjw=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="XUNh5FUfj/RmpaPcAHcjCQ=="/>
      </type>
      <system value="http://projectcrucible.org/GhlxiG2betJnvL9pTldMMQ=="/>
      <value value="Rv/GndNBj8cNJf2PX82sRQ=="/>
      <period>
        <start value="2017-10-19T02:41:35.048Z"/>
        <end value="2017-10-19T02:41:35.048Z"/>
      </period>
      <assigner>
        <display value="Organization HkVrvAWjjfMpr6UnqZrjsQ=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest SEoYYpH5Wz4MFzBmUMDV8w=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="FockGhel16WooaykOFanaQ=="/>
      </type>
      <system value="http://projectcrucible.org//B3p+NKld0mAW33/141o9Q=="/>
      <value value="dlgE6Ja3bpLJQ/dd4ix8jw=="/>
      <period>
        <start value="2017-10-19T02:41:35.048Z"/>
        <end value="2017-10-19T02:41:35.048Z"/>
      </period>
      <assigner>
        <display value="Organization K8hzmRJeJlxR5R/fERxiyQ=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest gB0kvdLJlHBhe5Kix41xWw=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="kvjzDMSkirUOFw44clRqyQ=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="relatedperson"/>
        <display value="RelatedPerson"/>
        <userSelected value="true"/>
      </coding>
      <text value="ot0dqWa/wrAXkpp9rN+a1w=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/2fb65Aa7q+UEsfD2QNXtOA=="/>
        <value value="LpdgUat7Mo8V5JZnLQJP8w=="/>
      </identifier>
      <display value="Organization TZBJV4l26EeM7FYxO1di9w=="/>
    </party>
  </payee>
  <information>
    <sequence value="28"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="attachment"/>
        <display value="Attachment"/>
        <userSelected value="true"/>
      </coding>
      <text value="4h365GAZVWYhHbGF1cI9qg=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="disabled"/>
        <display value="Disabled"/>
        <userSelected value="true"/>
      </coding>
      <text value="OviXtnSbdF3z8A7QXiq0OQ=="/>
    </code>
    <timingPeriod>
      <start value="2017-10-19T02:41:35.056Z"/>
      <end value="2017-10-19T02:41:35.056Z"/>
    </timingPeriod>
    <valueQuantity>
      <value value="0.5826867296315584"/>
      <comparator value="&lt;"/>
      <unit value="Add1N5z9tfsZhcHcC0liHg=="/>
      <system value="http://projectcrucible.org/J6mhW3MnTiqgZv2EKku7oA=="/>
      <code value="SQ6eazVs3mm7Lw3CFUsKDw=="/>
    </valueQuantity>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="o"/>
      <display value="O"/>
      <userSelected value="false"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="99"/>
    <provider>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/NzioaQ1k6kJWnHSd9elKOw=="/>
        <value value="5JU4j09ZzDTVI5OQeQ5Zcg=="/>
      </identifier>
      <display value="Organization 98dbqL3tvCqNf1w4BNKiDA=="/>
    </provider>
    <responsible value="true"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="primary"/>
        <display value="Primary provider"/>
        <userSelected value="true"/>
      </coding>
      <text value="X6udRvMcxCz+85vGbfjFJg=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="604210"/>
        <display value="Optometrist"/>
        <userSelected value="true"/>
      </coding>
      <text value="oI7j42/3uPBmO8gPc8Nqew=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="4"/>
    <diagnosisReference>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/WFBHXEDPREGbsJ/4mjojow=="/>
        <value value="wR7vHvsD+/BiK+LoqAzJFg=="/>
      </identifier>
      <display value="Condition 7Frj+tuUL1CzbSvEOWp7cw=="/>
    </diagnosisReference>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="differential"/>
        <display value="Differential Diagnosis"/>
        <userSelected value="false"/>
      </coding>
      <text value="zqADB9SaQwTFJCfwWN1t/w=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="101"/>
        <display value="Appendectomy - uncomplicated"/>
        <userSelected value="true"/>
      </coding>
      <text value="KogC3b/eVR30hH0emp8Jfg=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="73"/>
    <date value="2017-10-19T02:41:35.066Z"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
        <code value="123001"/>
        <display value="PROC-1"/>
        <userSelected value="true"/>
      </coding>
      <text value="xj2JVy4WV8xJeo2qMQKqPQ=="/>
    </procedureCodeableConcept>
  </procedure>
  <precedence value="51"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/Lh0hNolMgPtUWkhZcl5P4w=="/>
        <value value="mbbUYyRawKxLAed4mUZVkA=="/>
      </identifier>
      <display value="Coverage 7UBvQSsWAUHquBnOjunL2g=="/>
    </coverage>
    <preAuthRef value="daHf/mXZliVMjetuKmDyAw=="/>
  </insurance>
  <accident>
    <date value="2017-10-19"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="SCHOOL"/>
        <display value="School Accident"/>
        <userSelected value="true"/>
      </coding>
      <text value="n2enmPFdt4uPuinQXwIaDQ=="/>
    </type>
    <locationAddress>
      <use value="temp"/>
      <type value="physical"/>
      <text value="LOg2cz4Ye61XHWnIM8ZO9Q=="/>
      <line value="jTd+3pDTmYaTxJ5Vjg0REQ=="/>
      <city value="uPiOtZmW/pyn1JK6U40aHg=="/>
      <district value="XE9UtPQPBFN5IxnVec4E2g=="/>
      <state value="QAbvFCqqljmIY5Kd+VZ+Qg=="/>
      <postalCode value="tjDvwLdirv+sraPHsxQ2yQ=="/>
      <country value="Okx+SuD+VY3PLdKaFtgQbw=="/>
      <period>
        <start value="2017-10-19T02:41:35.070Z"/>
        <end value="2017-10-19T02:41:35.070Z"/>
      </period>
    </locationAddress>
  </accident>
  <employmentImpacted>
    <start value="2017-10-19T02:41:35.070Z"/>
    <end value="2017-10-19T02:41:35.070Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-19T02:41:35.071Z"/>
    <end value="2017-10-19T02:41:35.071Z"/>
  </hospitalization>
  <item>
    <sequence value="46"/>
    <careTeamLinkId value="36"/>
    <diagnosisLinkId value="81"/>
    <procedureLinkId value="12"/>
    <informationLinkId value="51"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0440"/>
        <display value="Speech-Language Pathology"/>
        <userSelected value="false"/>
      </coding>
      <text value="p3CNeeEhe7tdbRgFHKZe9w=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="56"/>
        <display value="Medically Related Transportation"/>
        <userSelected value="true"/>
      </coding>
      <text value="Zrmyma16qz1chsG9Fq5KGg=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="2141"/>
        <display value="Radiograph, bytewing"/>
        <userSelected value="true"/>
      </coding>
      <text value="zexm/C5zwx+5ulU1djGgDQ=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="x"/>
        <display value="None"/>
        <userSelected value="false"/>
      </coding>
      <text value="m/y1j+839vAZOTC+SbF/pA=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="hd"/>
        <display value="Heamodialisis"/>
        <userSelected value="true"/>
      </coding>
      <text value="b0ebZ6Ydxr7q8GKGtFYuEQ=="/>
    </programCode>
    <servicedDate value="2017-10-19"/>
    <locationAddress>
      <use value="work"/>
      <type value="physical"/>
      <text value="nyrUfyVtmCpAhB2CAa50DQ=="/>
      <line value="bj2I/SMdkYeJYBUewLcJrw=="/>
      <city value="ENsOw0285m//XNYH4fz8NQ=="/>
      <district value="Kl0R2vhIHsoIOYiXnOe3Jg=="/>
      <state value="dKHuPbKPp+nS2OdJwJqpJQ=="/>
      <postalCode value="zibtzoIk1X39YO7Oqy7urA=="/>
      <country value="zaO8CU8S6B6tOs9tOFoUJA=="/>
      <period>
        <start value="2017-10-19T02:41:35.079Z"/>
        <end value="2017-10-19T02:41:35.079Z"/>
      </period>
    </locationAddress>
    <quantity>
      <value value="0.4536188450154265"/>
      <unit value="Rga/ZzneNEJfm6+X8KPqYw=="/>
      <system value="http://projectcrucible.org/ZN4Fs9TG0tO5iLX+ulv4Xg=="/>
      <code value="3HkwqtKlVrGj289YG3rQVQ=="/>
    </quantity>
    <unitPrice>
      <value value="0.3564845005341768"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.6011764758037178"/>
    <net>
      <value value="0.3694641344539823"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/hKenx7SEI5pCCe3tMfxtNA=="/>
        <value value="sEE5k1IV8IS+e1+by+c5Og=="/>
      </identifier>
      <display value="Device KZtFr5He7c5h/uPqXv3Alw=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="34"/>
        <display value="34"/>
        <userSelected value="true"/>
      </coding>
      <text value="Dg+dc/EkeWoLnyslXURplg=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="DO"/>
        <display value="Distoclusal"/>
        <userSelected value="false"/>
      </coding>
      <text value="BOy7y9fcG+sQUCeZ78ws1g=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/bELXF0Nb1JD0IkgnFtw5rw=="/>
        <value value="VWNw453E58tFuYer87vyyw=="/>
      </identifier>
      <display value="Encounter hAbDr+MxPihhqURKVguMgA=="/>
    </encounter>
    <noteNumber value="94"/>
    <adjudication>
      <category>
        <text value="b0/TjieCHjzKXs6sLhAbIQ=="/>
      </category>
      <reason>
        <text value="l/8NMpF7IRBPXxkqt7+qtQ=="/>
      </reason>
      <amount>
        <value value="0.8534002971353912"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.5963072787426238"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="81"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0370"/>
        <display value="Anaesthesia"/>
        <userSelected value="true"/>
      </coding>
      <text value="NulvV7qmI89oA3nzbNJucg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="63"/>
        <display value="Donor Procedures"/>
        <userSelected value="false"/>
      </coding>
      <text value="kZS0zV2lJN356D/VFWOAag=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="21212"/>
        <display value="Amalgam, 2 surface"/>
        <userSelected value="false"/>
      </coding>
      <text value="kWGU/DWAbC5nkU8lNHIrEg=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="x"/>
        <display value="None"/>
        <userSelected value="true"/>
      </coding>
      <text value="80AHr0YoGzH46NsDEXbLSQ=="/>
    </modifier>
    <fee>
      <value value="0.21651993572389738"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="93"/>
    <adjudication>
      <category>
        <text value="r4r475oG1hPxJGlnrwAgwg=="/>
      </category>
      <reason>
        <text value="baFn5lFPoSSqc3nQ2kSkmg=="/>
      </reason>
      <amount>
        <value value="0.050525614613182945"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.7886635249045438"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.057348967202329404"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.15406615784532363"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.1484939157712606"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="tobaQntTDHSsUOjzvvW1eQ=="/>
    </type>
    <adjustment>
      <value value="0.4552990322401598"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a001"/>
        <display value="Prior Payment Reversal"/>
        <userSelected value="true"/>
      </coding>
      <text value="8Q8+RSVFt6jMf3ogdYR9Zw=="/>
    </adjustmentReason>
    <date value="2017-10-19"/>
    <amount>
      <value value="0.9254543628020406"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="3TRfUM3Gw/W/xzWpZpa1hg=="/>
      </type>
      <system value="http://projectcrucible.org/3Hre/B/J6XBeCqXBGtQqjQ=="/>
      <value value="CxjNrp1rBwygj0E8PUOz2Q=="/>
      <period>
        <start value="2017-10-19T02:41:35.101Z"/>
        <end value="2017-10-19T02:41:35.101Z"/>
      </period>
      <assigner>
        <display value="Organization mypcbt9uvQE4lMTlHiT8FA=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="xf6GSeGEUuSAyzNRdUOlww=="/>
  </form>
  <processNote>
    <number value="33"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="display"/>
        <display value="Display"/>
        <userSelected value="false"/>
      </coding>
      <text value="UVThjmoFqZpE6+n0ztfFYQ=="/>
    </type>
    <text value="7R7jmiYj0FBtIY3TJ1yB1Q=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="ja"/>
        <display value="Japansk"/>
        <userSelected value="false"/>
      </coding>
      <text value="kKDaR3H5eY5BT+JplhRumg=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="medical"/>
        <display value="Medical Health Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="KrZAnJDZxrlQ1oQzN21Ngw=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="26"/>
        <display value="Endodontics"/>
        <userSelected value="true"/>
      </coding>
      <text value="W6WjP8QQuLWh+1+vXhPswA=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="kXyOV2Hz76D6ZmOZANVMIw=="/>
    <description value="kerUkpLKn4BP8/H3/ptdAA=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="out"/>
        <display value="Out of Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="a6ELtV+KqV33tFvMa2+cPA=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="individual"/>
        <display value="Individual"/>
        <userSelected value="true"/>
      </coding>
      <text value="ULJEwi2vK3qrlynivbWUJw=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="day"/>
        <display value="Day"/>
        <userSelected value="false"/>
      </coding>
      <text value="y68RGz4tZGGrrlWwDtQPaQ=="/>
    </term>
    <financial>
      <type>
        <text value="iWTUlyjrUthyh2ioMtG6dw=="/>
      </type>
      <allowedString value="4GU7x6AlIGx9r4j3tIRWQA=="/>
      <usedMoney>
        <value value="0.6028659239324454"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

nil?

nil?

ExplanationOfBenefit "12" Version "2"

Updated by ANONYMOUS (Unknown) at 10/16/2017 7:06:45 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

l8wGrCqpLvS/cwtqLmY4HQ==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="12"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2017-10-16T07:06:45Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="fi"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">l8wGrCqpLvS/cwtqLmY4HQ==</div>
  </text>
  <identifier>
    <use value="temp"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v2/0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
        <userSelected value="false"/>
      </coding>
      <text value="vJNq0V9tKficsBLBY5yPDw=="/>
    </type>
    <system value="http://projectcrucible.org/TUoNX6kktAfBh0HmU6+qHQ=="/>
    <value value="N4uFD9hR82/5KRPGwNAjNQ=="/>
    <period>
      <start value="2017-10-16T03:06:44.610Z"/>
      <end value="2017-10-16T03:06:44.610Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/XFBP/c7NtC7CW+5cgUJInQ=="/>
        <value value="5EjGqM2DPkCtDxyS/hTg8g=="/>
      </identifier>
      <display value="Organization WpwZMJYka5RVRLpHsaxkLw=="/>
    </assigner>
  </identifier>
  <status value="cancelled"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="oral"/>
      <display value="Oral"/>
      <userSelected value="false"/>
    </coding>
    <text value="cwXINRbeltcz0z/R8f+YgQ=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="emergency"/>
      <display value="Emergency Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="aILf0c6VJ6kfJ5QYcZ4OYg=="/>
  </subType>
  <patient>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="0D2ur6EGzgShU9R+UatYSw=="/>
      </type>
      <system value="http://projectcrucible.org/z0boqQ2JjvRu6S4isc4alw=="/>
      <value value="uLlKdziSofwG8Fh385Jdhg=="/>
      <period>
        <start value="2017-10-16T03:06:44.613Z"/>
        <end value="2017-10-16T03:06:44.613Z"/>
      </period>
      <assigner>
        <display value="Organization B2dhFAu6b++kZfPialasvg=="/>
      </assigner>
    </identifier>
    <display value="Patient ACi7+67OejAuXVty62LlGA=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-16T03:06:44.613Z"/>
    <end value="2017-10-16T03:06:44.613Z"/>
  </billablePeriod>
  <created value="2017-10-16T03:06:45.221Z"/>
  <enterer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="HlhFjDSd/xCQWCc9g5qK7Q=="/>
      </type>
      <system value="http://projectcrucible.org/EZwTd5c6gm4sBjxR1STzNQ=="/>
      <value value="GcnkjB5xCEBLTRtPATV/Vw=="/>
      <period>
        <start value="2017-10-16T03:06:44.614Z"/>
        <end value="2017-10-16T03:06:44.614Z"/>
      </period>
      <assigner>
        <display value="Organization EnsHW19R32tpT4/Q7CgmXA=="/>
      </assigner>
    </identifier>
    <display value="Practitioner fKS3PvnMOrjkyeVRSRZKPg=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="official"/>
      <type>
        <text value="MwpHvW0Gur92F/t9SwkiKA=="/>
      </type>
      <system value="http://projectcrucible.org/0XZoJjlQUCgGB1TXC8mHrQ=="/>
      <value value="1umNv6/igOPAEUmvzo/4dQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.614Z"/>
        <end value="2017-10-16T03:06:44.614Z"/>
      </period>
      <assigner>
        <display value="Organization 2Uj/SvPbMAx84/K7FSc/2Q=="/>
      </assigner>
    </identifier>
    <display value="Organization LuNmIy5ndlCRHSFhdQHXeA=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="+ZCn1s+lclSvznOUW9914g=="/>
      </type>
      <system value="http://projectcrucible.org/Idzf8H9X5mfbDIyfpO9T9g=="/>
      <value value="UJYj+VuU9sZLEvtGwuil7Q=="/>
      <period>
        <start value="2017-10-16T03:06:44.615Z"/>
        <end value="2017-10-16T03:06:44.615Z"/>
      </period>
      <assigner>
        <display value="Organization L/oYvIynHacRPQ0YSrYelA=="/>
      </assigner>
    </identifier>
    <display value="Practitioner HGKU+Z1rSUhJnYJmdzutzw=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="1eJZx/7U0N65a49hy8FjcA=="/>
      </type>
      <system value="http://projectcrucible.org/BCBZ0JA80FO9ml/S6iYwQg=="/>
      <value value="qxgKyqzoY9KEHBcqQCu1gQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.615Z"/>
        <end value="2017-10-16T03:06:44.615Z"/>
      </period>
      <assigner>
        <display value="Organization /kai5Mb28LxLUTcvOr3pew=="/>
      </assigner>
    </identifier>
    <display value="Organization uUEqy81kgvF0GNm0qS6xhw=="/>
  </organization>
  <referral>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="lVnBiWxrhMmqJeUp0MVkOQ=="/>
      </type>
      <system value="http://projectcrucible.org/RILqnr6OazUVGYWDP6LFTQ=="/>
      <value value="XrZW6BqUQXIocDoy3UraHg=="/>
      <period>
        <start value="2017-10-16T03:06:44.616Z"/>
        <end value="2017-10-16T03:06:44.616Z"/>
      </period>
      <assigner>
        <display value="Organization CKJ5yCJboZuzKo0TW6+mqw=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest HYA58e98hpW+0gJTccPVhg=="/>
  </referral>
  <facility>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="GXdRcZTsvPcRWAKfFsnqZg=="/>
      </type>
      <system value="http://projectcrucible.org/w56qo33StYi5WP4nQ24WUg=="/>
      <value value="CEh/LgU7Q1rDc7TKGhTm7g=="/>
      <period>
        <start value="2017-10-16T03:06:44.617Z"/>
        <end value="2017-10-16T03:06:44.617Z"/>
      </period>
      <assigner>
        <display value="Organization hRcKWdM6BTGCMNrBhrxybA=="/>
      </assigner>
    </identifier>
    <display value="Location tqPrGsXY1dnx5RX8iKlMOA=="/>
  </facility>
  <claim>
    <identifier>
      <use value="official"/>
      <type>
        <text value="q96tHmpgXwXLdZ4UGwry+g=="/>
      </type>
      <system value="http://projectcrucible.org/fjrKWoTrCD9jgMoNX0pmug=="/>
      <value value="a/v8YGOVMk+Bg/VMM9wixg=="/>
      <period>
        <start value="2017-10-16T03:06:44.617Z"/>
        <end value="2017-10-16T03:06:44.617Z"/>
      </period>
      <assigner>
        <display value="Organization qdJpFx5kwnRtvso26XkHWQ=="/>
      </assigner>
    </identifier>
    <display value="Claim 8ijZO5ae9G9nyWQp3KO6ng=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="official"/>
      <type>
        <text value="r4Im1Ja9yd7u2EDmuRRLAA=="/>
      </type>
      <system value="http://projectcrucible.org/tcyAQOgV4n3tsMPNmVLdAA=="/>
      <value value="IjjkOjEivIoRGJwoSP4DcA=="/>
      <period>
        <start value="2017-10-16T03:06:44.618Z"/>
        <end value="2017-10-16T03:06:44.618Z"/>
      </period>
      <assigner>
        <display value="Organization PsVrRoQmxwdt7TgrXwTF6w=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse aHdHSpWtpCnU65a3lWymNA=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
      <display value="Processing Complete"/>
      <userSelected value="false"/>
    </coding>
    <text value="iWxV7Os06s7KRlgZgtSU9g=="/>
  </outcome>
  <disposition value="pW+4nVeqAaIxyJ+6OCPSCA=="/>
  <related>
    <claim>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/I1/GdSOlQGlmyzOOD2kr4Q=="/>
        <value value="AQwopoZQdxZOiGeqQ631ng=="/>
      </identifier>
      <display value="Claim 3iMqz500VCvG+26NdkQg5A=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="3suCQ1pGZttblmuDX3UrTA=="/>
    </relationship>
    <reference>
      <use value="official"/>
      <type>
        <text value="Y5gP4zCIOT+sLz40H7m0bA=="/>
      </type>
      <system value="http://projectcrucible.org/Dsr07BGdYcVsizjO66wdfQ=="/>
      <value value="aRtHc9yvfoG0A4ZFHYcDMQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.621Z"/>
        <end value="2017-10-16T03:06:44.621Z"/>
      </period>
      <assigner>
        <display value="Organization VkgZCPArRB/gUfZl1pGp8w=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="gHGVY4eTOXcW0llPwzmbZQ=="/>
      </type>
      <system value="http://projectcrucible.org/XsL2EKA8FkGukV1Zc2v86g=="/>
      <value value="AuTYnnJBCncOiwCmrp5XmQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.621Z"/>
        <end value="2017-10-16T03:06:44.621Z"/>
      </period>
      <assigner>
        <display value="Organization 01SRNpH9VsRp3rEvdUe39w=="/>
      </assigner>
    </identifier>
    <display value="VisionPrescription xdYcIYsicanY/mjuvDQaKQ=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="YgHeOB3wet/VUFxjA2i6hA=="/>
      </type>
      <system value="http://projectcrucible.org/AURgvHWSSYBwTLFThSyUbw=="/>
      <value value="MC/lTq6D41AcmjBgr3hzYw=="/>
      <period>
        <start value="2017-10-16T03:06:44.622Z"/>
        <end value="2017-10-16T03:06:44.622Z"/>
      </period>
      <assigner>
        <display value="Organization 3w+FNbdiZNfkbx/B6oNV5w=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest /lVTKaTN1Dhi32n9S62ccw=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="hCqntTP8MOV2bXuq6K2INQ=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="patient"/>
        <display value="Patient"/>
        <userSelected value="false"/>
      </coding>
      <text value="IB1ikb8Q8MQJQlG5sXfWuw=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/qt0tRUGkTNPZRHzXQfgGlA=="/>
        <value value="sAOmqLqJijU+8Zmx7GaNHg=="/>
      </identifier>
      <display value="Patient mPhBeS5iPMJ1moONyi78gQ=="/>
    </party>
  </payee>
  <information>
    <sequence value="11"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="true"/>
      </coding>
      <text value="t3fDqvpF5Ex3HbFEHSXzbA=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="student"/>
        <display value="Student (Fulltime)"/>
        <userSelected value="true"/>
      </coding>
      <text value="qf4u9DqUuo1Lo7P9dGoujg=="/>
    </code>
    <timingDate value="2017-10-16"/>
    <valueString value="YWpMyfHtXyPEUgEm0cRVnA=="/>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="u"/>
      <display value="U"/>
      <userSelected value="true"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="45"/>
    <provider>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/aCQJxrZUKRq+Kb1QuqGXXA=="/>
        <value value="OqOahfYwt1JNtRrkqnD1Hw=="/>
      </identifier>
      <display value="Practitioner V3aCLn5M10a5TWrJ3pOeFg=="/>
    </provider>
    <responsible value="true"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="false"/>
      </coding>
      <text value="Wbddtt1jH9nSIAFrGkUijg=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="true"/>
      </coding>
      <text value="BokCiyv+ZbruVmWl0yGnrA=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="29"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/h8I8Z0RbPD5yVUcnIMWkRQ=="/>
        <code value="lplHrJ/a8icB0+PnNTcYGw=="/>
        <display value="s0I84ILkO2OtpgPwjK1mgg=="/>
        <userSelected value="true"/>
      </coding>
      <text value="zyyjYI0qt9xBP+SjjcjwSA=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="differential"/>
        <display value="Differential Diagnosis"/>
        <userSelected value="true"/>
      </coding>
      <text value="X3ng20XtcIsUBY09p62Z3Q=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="400"/>
        <display value="Head trauma - concussion"/>
        <userSelected value="true"/>
      </coding>
      <text value="URhYZtG0bBF2oR/VLz1TBw=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="22"/>
    <date value="2017-10-16T03:06:44.635Z"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
        <code value="123001"/>
        <display value="PROC-1"/>
        <userSelected value="false"/>
      </coding>
      <text value="6YsLzoBl1oXhY15G/6C+zw=="/>
    </procedureCodeableConcept>
  </procedure>
  <precedence value="78"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/kgZlf9OfT3+jKJuF4Yjgdw=="/>
        <value value="UNNX1ypolIXYulyZ8vel4A=="/>
      </identifier>
      <display value="Coverage o2Cjx0JpgZDjFvBdz6Ttgw=="/>
    </coverage>
    <preAuthRef value="woCkAeV7bNeXds69EzTJ6A=="/>
  </insurance>
  <accident>
    <date value="2017-10-16"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="WPA"/>
        <display value="Workplace accident"/>
        <userSelected value="true"/>
      </coding>
      <text value="/8aerpLo9yUaHdsixph1yw=="/>
    </type>
    <locationAddress>
      <use value="home"/>
      <type value="both"/>
      <text value="AwASaGcVm08Mh/z0NcQeog=="/>
      <line value="SUWEj6HAWPHLoltjZXMc1g=="/>
      <city value="1HpBkoqtY3X3bZ6vmhmJKg=="/>
      <district value="q9LAqmeycewmXVdP+1XNEA=="/>
      <state value="j7V8/opXMViJA5yvjyHa7Q=="/>
      <postalCode value="sirJimFk0YNnNuPWcpIiYg=="/>
      <country value="LjQwEugMAhp51Naj9dYRlg=="/>
      <period>
        <start value="2017-10-16T03:06:44.640Z"/>
        <end value="2017-10-16T03:06:44.640Z"/>
      </period>
    </locationAddress>
  </accident>
  <employmentImpacted>
    <start value="2017-10-16T03:06:44.640Z"/>
    <end value="2017-10-16T03:06:44.640Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-16T03:06:44.640Z"/>
    <end value="2017-10-16T03:06:44.640Z"/>
  </hospitalization>
  <item>
    <sequence value="36"/>
    <careTeamLinkId value="37"/>
    <diagnosisLinkId value="91"/>
    <procedureLinkId value="26"/>
    <informationLinkId value="31"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0370"/>
        <display value="Anaesthesia"/>
        <userSelected value="false"/>
      </coding>
      <text value="AbsEWVFS0/UzKHehCvOlgg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="61"/>
        <display value="In-vitro Fertilization"/>
        <userSelected value="true"/>
      </coding>
      <text value="a2p5sLoelwvRUen8CYJg4g=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="27211"/>
        <display value="Crown, PFM"/>
        <userSelected value="false"/>
      </coding>
      <text value="bc/L3tWwF6VkL/4AgSFEvw=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="0ZjFOpLwiZ2T10dAb6kc6w=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="none"/>
        <display value="None"/>
        <userSelected value="true"/>
      </coding>
      <text value="OiXdM5w7GbtTsyhxw77Vkw=="/>
    </programCode>
    <servicedDate value="2017-10-16"/>
    <locationCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/ex-serviceplace"/>
        <code value="08"/>
        <display value="Tribal 638 Provider-Based Facility"/>
        <userSelected value="false"/>
      </coding>
      <text value="a+HwnhBcny17DRzfxMSVPg=="/>
    </locationCodeableConcept>
    <quantity>
      <value value="0.5049499845648618"/>
      <unit value="cEWfn9tp62MTQwx9HvyoJg=="/>
      <system value="http://projectcrucible.org/Ki7tin4RMIjwdg8DX3wWOw=="/>
      <code value="oXLphiL/pUu9gCWXRaYRag=="/>
    </quantity>
    <unitPrice>
      <value value="0.5580725316841824"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.35571877750810843"/>
    <net>
      <value value="0.3971552811403509"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/LiMETIexVL5Kie6CeusTww=="/>
        <value value="fjAAvo/kUkPiRTqrDg4NfQ=="/>
      </identifier>
      <display value="Device CxWDvZJ9WYLVjYvdaCr+UQ=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="25"/>
        <display value="25"/>
        <userSelected value="false"/>
      </coding>
      <text value="on7pxaUD1vIKd3u2SCJj6w=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="M"/>
        <display value="Mesial"/>
        <userSelected value="true"/>
      </coding>
      <text value="qHW8Ke0U5Y49qz5t/sIEhQ=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/lcur9506ZtZRfGI60FluxQ=="/>
        <value value="Vd9RJXv/yaYOsDteT+hqOg=="/>
      </identifier>
      <display value="Encounter LVUZWwa9gFMvfowd13ckIw=="/>
    </encounter>
    <noteNumber value="1"/>
    <adjudication>
      <category>
        <text value="snxSW74UTp3jQmkxNa5Zlg=="/>
      </category>
      <reason>
        <text value="fpsW4wDKUVF261U2NhX0sg=="/>
      </reason>
      <amount>
        <value value="0.8211594871191155"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.8752727137942531"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="71"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0421"/>
        <display value="Physical Therapy -"/>
        <userSelected value="true"/>
      </coding>
      <text value="FRtCoFnknFjT5BAYKzQGdg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="69"/>
        <display value="Maternity"/>
        <userSelected value="true"/>
      </coding>
      <text value="5HfMuO55zvRgtQ12WC/Uow=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="99555"/>
        <display value="Expense"/>
        <userSelected value="false"/>
      </coding>
      <text value="25THt5agvCzJ+7u5ElN3xg=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="Kf7kyhTvMge7Uwbp0cE3yQ=="/>
    </modifier>
    <fee>
      <value value="0.5298423473750238"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="7"/>
    <adjudication>
      <category>
        <text value="94Qs6Rt5WT2Yij0ZIj3EiA=="/>
      </category>
      <reason>
        <text value="hjA1E5huxsxOKiRvuXy6xA=="/>
      </reason>
      <amount>
        <value value="0.8346581840028171"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.036228412754247485"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.9459452034314311"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.9648191075670238"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.150270384963203"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="XDzUjOeLCEGN+OvMKojOJQ=="/>
    </type>
    <adjustment>
      <value value="0.33069354559495023"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a002"/>
        <display value="Prior Overpayment"/>
        <userSelected value="true"/>
      </coding>
      <text value="7AuyFy0q600AwEDIx0HgxA=="/>
    </adjustmentReason>
    <date value="2017-10-16"/>
    <amount>
      <value value="0.7826881698884735"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="official"/>
      <type>
        <text value="9LzFAsOLKXXgCnNApNde9A=="/>
      </type>
      <system value="http://projectcrucible.org/vIwykhM7ROD0VpDTMKyKkQ=="/>
      <value value="7mwk5T4cyhuD2XxY/bsgLA=="/>
      <period>
        <start value="2017-10-16T03:06:44.677Z"/>
        <end value="2017-10-16T03:06:44.677Z"/>
      </period>
      <assigner>
        <display value="Organization fs6PweDK65tzIpbjoyGDcg=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="9EqGrD8oaYRaIUcF444JJA=="/>
  </form>
  <processNote>
    <number value="11"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="print"/>
        <display value="Print (Form)"/>
        <userSelected value="false"/>
      </coding>
      <text value="2o5BYGTtOGrbmfCLi0R0sA=="/>
    </type>
    <text value="AcjIo9nLqALmg4BJYqA5fQ=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="hr"/>
        <display value="Kroatisk"/>
        <userSelected value="false"/>
      </coding>
      <text value="jrN3ATqyj77kjSa6YDQIjQ=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="vision"/>
        <display value="Vision Health Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="x5rBc+Ed4+STLUJu2UwALA=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="F4"/>
        <display value="Hearing Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="oZEAOnjfEAMgGmXa724K6w=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="SisG1mJd0vFq9zIHp8kSeg=="/>
    <description value="TuTm+CXXmVbX9jIv8LIG9A=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="in"/>
        <display value="In Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="MixNMNduNhjsZVdFG8ZKaQ=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="individual"/>
        <display value="Individual"/>
        <userSelected value="false"/>
      </coding>
      <text value="JMxwttxkHikjrxbC2VQY7A=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="lifetime"/>
        <display value="Lifetime"/>
        <userSelected value="true"/>
      </coding>
      <text value="SLv42q7xrs3OoN6HTduYVg=="/>
    </term>
    <financial>
      <type>
        <text value="xaOJ/GJrqS/4+f+YeZykYw=="/>
      </type>
      <allowedMoney>
        <value value="0.11653396525216353"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </allowedMoney>
      <usedMoney>
        <value value="0.7675381243575978"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

ExplanationOfBenefit "12" Version "1"

Created by ANONYMOUS (Unknown) at 10/16/2017 7:06:44 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

l8wGrCqpLvS/cwtqLmY4HQ==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="12"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-10-16T07:06:44Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="pa"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">l8wGrCqpLvS/cwtqLmY4HQ==</div>
  </text>
  <identifier>
    <use value="temp"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v2/0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
        <userSelected value="false"/>
      </coding>
      <text value="vJNq0V9tKficsBLBY5yPDw=="/>
    </type>
    <system value="http://projectcrucible.org/TUoNX6kktAfBh0HmU6+qHQ=="/>
    <value value="N4uFD9hR82/5KRPGwNAjNQ=="/>
    <period>
      <start value="2017-10-16T03:06:44.610Z"/>
      <end value="2017-10-16T03:06:44.610Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/XFBP/c7NtC7CW+5cgUJInQ=="/>
        <value value="5EjGqM2DPkCtDxyS/hTg8g=="/>
      </identifier>
      <display value="Organization WpwZMJYka5RVRLpHsaxkLw=="/>
    </assigner>
  </identifier>
  <status value="draft"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="oral"/>
      <display value="Oral"/>
      <userSelected value="false"/>
    </coding>
    <text value="cwXINRbeltcz0z/R8f+YgQ=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="emergency"/>
      <display value="Emergency Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="aILf0c6VJ6kfJ5QYcZ4OYg=="/>
  </subType>
  <patient>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="0D2ur6EGzgShU9R+UatYSw=="/>
      </type>
      <system value="http://projectcrucible.org/z0boqQ2JjvRu6S4isc4alw=="/>
      <value value="uLlKdziSofwG8Fh385Jdhg=="/>
      <period>
        <start value="2017-10-16T03:06:44.613Z"/>
        <end value="2017-10-16T03:06:44.613Z"/>
      </period>
      <assigner>
        <display value="Organization B2dhFAu6b++kZfPialasvg=="/>
      </assigner>
    </identifier>
    <display value="Patient ACi7+67OejAuXVty62LlGA=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-16T03:06:44.613Z"/>
    <end value="2017-10-16T03:06:44.613Z"/>
  </billablePeriod>
  <created value="2017-10-16T03:06:44.613Z"/>
  <enterer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="HlhFjDSd/xCQWCc9g5qK7Q=="/>
      </type>
      <system value="http://projectcrucible.org/EZwTd5c6gm4sBjxR1STzNQ=="/>
      <value value="GcnkjB5xCEBLTRtPATV/Vw=="/>
      <period>
        <start value="2017-10-16T03:06:44.614Z"/>
        <end value="2017-10-16T03:06:44.614Z"/>
      </period>
      <assigner>
        <display value="Organization EnsHW19R32tpT4/Q7CgmXA=="/>
      </assigner>
    </identifier>
    <display value="Practitioner fKS3PvnMOrjkyeVRSRZKPg=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="official"/>
      <type>
        <text value="MwpHvW0Gur92F/t9SwkiKA=="/>
      </type>
      <system value="http://projectcrucible.org/0XZoJjlQUCgGB1TXC8mHrQ=="/>
      <value value="1umNv6/igOPAEUmvzo/4dQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.614Z"/>
        <end value="2017-10-16T03:06:44.614Z"/>
      </period>
      <assigner>
        <display value="Organization 2Uj/SvPbMAx84/K7FSc/2Q=="/>
      </assigner>
    </identifier>
    <display value="Organization LuNmIy5ndlCRHSFhdQHXeA=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="+ZCn1s+lclSvznOUW9914g=="/>
      </type>
      <system value="http://projectcrucible.org/Idzf8H9X5mfbDIyfpO9T9g=="/>
      <value value="UJYj+VuU9sZLEvtGwuil7Q=="/>
      <period>
        <start value="2017-10-16T03:06:44.615Z"/>
        <end value="2017-10-16T03:06:44.615Z"/>
      </period>
      <assigner>
        <display value="Organization L/oYvIynHacRPQ0YSrYelA=="/>
      </assigner>
    </identifier>
    <display value="Practitioner HGKU+Z1rSUhJnYJmdzutzw=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="1eJZx/7U0N65a49hy8FjcA=="/>
      </type>
      <system value="http://projectcrucible.org/BCBZ0JA80FO9ml/S6iYwQg=="/>
      <value value="qxgKyqzoY9KEHBcqQCu1gQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.615Z"/>
        <end value="2017-10-16T03:06:44.615Z"/>
      </period>
      <assigner>
        <display value="Organization /kai5Mb28LxLUTcvOr3pew=="/>
      </assigner>
    </identifier>
    <display value="Organization uUEqy81kgvF0GNm0qS6xhw=="/>
  </organization>
  <referral>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="lVnBiWxrhMmqJeUp0MVkOQ=="/>
      </type>
      <system value="http://projectcrucible.org/RILqnr6OazUVGYWDP6LFTQ=="/>
      <value value="XrZW6BqUQXIocDoy3UraHg=="/>
      <period>
        <start value="2017-10-16T03:06:44.616Z"/>
        <end value="2017-10-16T03:06:44.616Z"/>
      </period>
      <assigner>
        <display value="Organization CKJ5yCJboZuzKo0TW6+mqw=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest HYA58e98hpW+0gJTccPVhg=="/>
  </referral>
  <facility>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="GXdRcZTsvPcRWAKfFsnqZg=="/>
      </type>
      <system value="http://projectcrucible.org/w56qo33StYi5WP4nQ24WUg=="/>
      <value value="CEh/LgU7Q1rDc7TKGhTm7g=="/>
      <period>
        <start value="2017-10-16T03:06:44.617Z"/>
        <end value="2017-10-16T03:06:44.617Z"/>
      </period>
      <assigner>
        <display value="Organization hRcKWdM6BTGCMNrBhrxybA=="/>
      </assigner>
    </identifier>
    <display value="Location tqPrGsXY1dnx5RX8iKlMOA=="/>
  </facility>
  <claim>
    <identifier>
      <use value="official"/>
      <type>
        <text value="q96tHmpgXwXLdZ4UGwry+g=="/>
      </type>
      <system value="http://projectcrucible.org/fjrKWoTrCD9jgMoNX0pmug=="/>
      <value value="a/v8YGOVMk+Bg/VMM9wixg=="/>
      <period>
        <start value="2017-10-16T03:06:44.617Z"/>
        <end value="2017-10-16T03:06:44.617Z"/>
      </period>
      <assigner>
        <display value="Organization qdJpFx5kwnRtvso26XkHWQ=="/>
      </assigner>
    </identifier>
    <display value="Claim 8ijZO5ae9G9nyWQp3KO6ng=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="official"/>
      <type>
        <text value="r4Im1Ja9yd7u2EDmuRRLAA=="/>
      </type>
      <system value="http://projectcrucible.org/tcyAQOgV4n3tsMPNmVLdAA=="/>
      <value value="IjjkOjEivIoRGJwoSP4DcA=="/>
      <period>
        <start value="2017-10-16T03:06:44.618Z"/>
        <end value="2017-10-16T03:06:44.618Z"/>
      </period>
      <assigner>
        <display value="Organization PsVrRoQmxwdt7TgrXwTF6w=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse aHdHSpWtpCnU65a3lWymNA=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
      <display value="Processing Complete"/>
      <userSelected value="false"/>
    </coding>
    <text value="iWxV7Os06s7KRlgZgtSU9g=="/>
  </outcome>
  <disposition value="OeqQTsIEzoQX857Z24gCzQ=="/>
  <related>
    <claim>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/I1/GdSOlQGlmyzOOD2kr4Q=="/>
        <value value="AQwopoZQdxZOiGeqQ631ng=="/>
      </identifier>
      <display value="Claim 3iMqz500VCvG+26NdkQg5A=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="3suCQ1pGZttblmuDX3UrTA=="/>
    </relationship>
    <reference>
      <use value="official"/>
      <type>
        <text value="Y5gP4zCIOT+sLz40H7m0bA=="/>
      </type>
      <system value="http://projectcrucible.org/Dsr07BGdYcVsizjO66wdfQ=="/>
      <value value="aRtHc9yvfoG0A4ZFHYcDMQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.621Z"/>
        <end value="2017-10-16T03:06:44.621Z"/>
      </period>
      <assigner>
        <display value="Organization VkgZCPArRB/gUfZl1pGp8w=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="gHGVY4eTOXcW0llPwzmbZQ=="/>
      </type>
      <system value="http://projectcrucible.org/XsL2EKA8FkGukV1Zc2v86g=="/>
      <value value="AuTYnnJBCncOiwCmrp5XmQ=="/>
      <period>
        <start value="2017-10-16T03:06:44.621Z"/>
        <end value="2017-10-16T03:06:44.621Z"/>
      </period>
      <assigner>
        <display value="Organization 01SRNpH9VsRp3rEvdUe39w=="/>
      </assigner>
    </identifier>
    <display value="VisionPrescription xdYcIYsicanY/mjuvDQaKQ=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="YgHeOB3wet/VUFxjA2i6hA=="/>
      </type>
      <system value="http://projectcrucible.org/AURgvHWSSYBwTLFThSyUbw=="/>
      <value value="MC/lTq6D41AcmjBgr3hzYw=="/>
      <period>
        <start value="2017-10-16T03:06:44.622Z"/>
        <end value="2017-10-16T03:06:44.622Z"/>
      </period>
      <assigner>
        <display value="Organization 3w+FNbdiZNfkbx/B6oNV5w=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest /lVTKaTN1Dhi32n9S62ccw=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="hCqntTP8MOV2bXuq6K2INQ=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="patient"/>
        <display value="Patient"/>
        <userSelected value="false"/>
      </coding>
      <text value="IB1ikb8Q8MQJQlG5sXfWuw=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/qt0tRUGkTNPZRHzXQfgGlA=="/>
        <value value="sAOmqLqJijU+8Zmx7GaNHg=="/>
      </identifier>
      <display value="Patient mPhBeS5iPMJ1moONyi78gQ=="/>
    </party>
  </payee>
  <information>
    <sequence value="11"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="true"/>
      </coding>
      <text value="t3fDqvpF5Ex3HbFEHSXzbA=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="student"/>
        <display value="Student (Fulltime)"/>
        <userSelected value="true"/>
      </coding>
      <text value="qf4u9DqUuo1Lo7P9dGoujg=="/>
    </code>
    <timingDate value="2017-10-16"/>
    <valueString value="YWpMyfHtXyPEUgEm0cRVnA=="/>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="u"/>
      <display value="U"/>
      <userSelected value="true"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="45"/>
    <provider>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/aCQJxrZUKRq+Kb1QuqGXXA=="/>
        <value value="OqOahfYwt1JNtRrkqnD1Hw=="/>
      </identifier>
      <display value="Practitioner V3aCLn5M10a5TWrJ3pOeFg=="/>
    </provider>
    <responsible value="true"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="false"/>
      </coding>
      <text value="Wbddtt1jH9nSIAFrGkUijg=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="true"/>
      </coding>
      <text value="BokCiyv+ZbruVmWl0yGnrA=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="29"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/h8I8Z0RbPD5yVUcnIMWkRQ=="/>
        <code value="lplHrJ/a8icB0+PnNTcYGw=="/>
        <display value="s0I84ILkO2OtpgPwjK1mgg=="/>
        <userSelected value="true"/>
      </coding>
      <text value="zyyjYI0qt9xBP+SjjcjwSA=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="differential"/>
        <display value="Differential Diagnosis"/>
        <userSelected value="true"/>
      </coding>
      <text value="X3ng20XtcIsUBY09p62Z3Q=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="400"/>
        <display value="Head trauma - concussion"/>
        <userSelected value="true"/>
      </coding>
      <text value="URhYZtG0bBF2oR/VLz1TBw=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="22"/>
    <date value="2017-10-16T03:06:44.635Z"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
        <code value="123001"/>
        <display value="PROC-1"/>
        <userSelected value="false"/>
      </coding>
      <text value="6YsLzoBl1oXhY15G/6C+zw=="/>
    </procedureCodeableConcept>
  </procedure>
  <precedence value="67"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/kgZlf9OfT3+jKJuF4Yjgdw=="/>
        <value value="UNNX1ypolIXYulyZ8vel4A=="/>
      </identifier>
      <display value="Coverage o2Cjx0JpgZDjFvBdz6Ttgw=="/>
    </coverage>
    <preAuthRef value="woCkAeV7bNeXds69EzTJ6A=="/>
  </insurance>
  <accident>
    <date value="2017-10-16"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="WPA"/>
        <display value="Workplace accident"/>
        <userSelected value="true"/>
      </coding>
      <text value="/8aerpLo9yUaHdsixph1yw=="/>
    </type>
    <locationAddress>
      <use value="home"/>
      <type value="both"/>
      <text value="AwASaGcVm08Mh/z0NcQeog=="/>
      <line value="SUWEj6HAWPHLoltjZXMc1g=="/>
      <city value="1HpBkoqtY3X3bZ6vmhmJKg=="/>
      <district value="q9LAqmeycewmXVdP+1XNEA=="/>
      <state value="j7V8/opXMViJA5yvjyHa7Q=="/>
      <postalCode value="sirJimFk0YNnNuPWcpIiYg=="/>
      <country value="LjQwEugMAhp51Naj9dYRlg=="/>
      <period>
        <start value="2017-10-16T03:06:44.640Z"/>
        <end value="2017-10-16T03:06:44.640Z"/>
      </period>
    </locationAddress>
  </accident>
  <employmentImpacted>
    <start value="2017-10-16T03:06:44.640Z"/>
    <end value="2017-10-16T03:06:44.640Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-16T03:06:44.640Z"/>
    <end value="2017-10-16T03:06:44.640Z"/>
  </hospitalization>
  <item>
    <sequence value="36"/>
    <careTeamLinkId value="37"/>
    <diagnosisLinkId value="91"/>
    <procedureLinkId value="26"/>
    <informationLinkId value="31"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0370"/>
        <display value="Anaesthesia"/>
        <userSelected value="false"/>
      </coding>
      <text value="AbsEWVFS0/UzKHehCvOlgg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="61"/>
        <display value="In-vitro Fertilization"/>
        <userSelected value="true"/>
      </coding>
      <text value="a2p5sLoelwvRUen8CYJg4g=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="27211"/>
        <display value="Crown, PFM"/>
        <userSelected value="false"/>
      </coding>
      <text value="bc/L3tWwF6VkL/4AgSFEvw=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="0ZjFOpLwiZ2T10dAb6kc6w=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="none"/>
        <display value="None"/>
        <userSelected value="true"/>
      </coding>
      <text value="OiXdM5w7GbtTsyhxw77Vkw=="/>
    </programCode>
    <servicedDate value="2017-10-16"/>
    <locationCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/ex-serviceplace"/>
        <code value="08"/>
        <display value="Tribal 638 Provider-Based Facility"/>
        <userSelected value="false"/>
      </coding>
      <text value="a+HwnhBcny17DRzfxMSVPg=="/>
    </locationCodeableConcept>
    <quantity>
      <value value="0.5049499845648618"/>
      <unit value="cEWfn9tp62MTQwx9HvyoJg=="/>
      <system value="http://projectcrucible.org/Ki7tin4RMIjwdg8DX3wWOw=="/>
      <code value="oXLphiL/pUu9gCWXRaYRag=="/>
    </quantity>
    <unitPrice>
      <value value="0.5580725316841824"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.35571877750810843"/>
    <net>
      <value value="0.3971552811403509"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/LiMETIexVL5Kie6CeusTww=="/>
        <value value="fjAAvo/kUkPiRTqrDg4NfQ=="/>
      </identifier>
      <display value="Device CxWDvZJ9WYLVjYvdaCr+UQ=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="25"/>
        <display value="25"/>
        <userSelected value="false"/>
      </coding>
      <text value="on7pxaUD1vIKd3u2SCJj6w=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="M"/>
        <display value="Mesial"/>
        <userSelected value="true"/>
      </coding>
      <text value="qHW8Ke0U5Y49qz5t/sIEhQ=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/lcur9506ZtZRfGI60FluxQ=="/>
        <value value="Vd9RJXv/yaYOsDteT+hqOg=="/>
      </identifier>
      <display value="Encounter LVUZWwa9gFMvfowd13ckIw=="/>
    </encounter>
    <noteNumber value="1"/>
    <adjudication>
      <category>
        <text value="snxSW74UTp3jQmkxNa5Zlg=="/>
      </category>
      <reason>
        <text value="fpsW4wDKUVF261U2NhX0sg=="/>
      </reason>
      <amount>
        <value value="0.8211594871191155"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.8752727137942531"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="71"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0421"/>
        <display value="Physical Therapy -"/>
        <userSelected value="true"/>
      </coding>
      <text value="FRtCoFnknFjT5BAYKzQGdg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="69"/>
        <display value="Maternity"/>
        <userSelected value="true"/>
      </coding>
      <text value="5HfMuO55zvRgtQ12WC/Uow=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="99555"/>
        <display value="Expense"/>
        <userSelected value="false"/>
      </coding>
      <text value="25THt5agvCzJ+7u5ElN3xg=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="Kf7kyhTvMge7Uwbp0cE3yQ=="/>
    </modifier>
    <fee>
      <value value="0.5298423473750238"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="7"/>
    <adjudication>
      <category>
        <text value="94Qs6Rt5WT2Yij0ZIj3EiA=="/>
      </category>
      <reason>
        <text value="hjA1E5huxsxOKiRvuXy6xA=="/>
      </reason>
      <amount>
        <value value="0.8346581840028171"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.036228412754247485"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.9459452034314311"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.9648191075670238"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.150270384963203"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="XDzUjOeLCEGN+OvMKojOJQ=="/>
    </type>
    <adjustment>
      <value value="0.33069354559495023"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a002"/>
        <display value="Prior Overpayment"/>
        <userSelected value="true"/>
      </coding>
      <text value="7AuyFy0q600AwEDIx0HgxA=="/>
    </adjustmentReason>
    <date value="2017-10-16"/>
    <amount>
      <value value="0.7826881698884735"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="official"/>
      <type>
        <text value="9LzFAsOLKXXgCnNApNde9A=="/>
      </type>
      <system value="http://projectcrucible.org/vIwykhM7ROD0VpDTMKyKkQ=="/>
      <value value="7mwk5T4cyhuD2XxY/bsgLA=="/>
      <period>
        <start value="2017-10-16T03:06:44.677Z"/>
        <end value="2017-10-16T03:06:44.677Z"/>
      </period>
      <assigner>
        <display value="Organization fs6PweDK65tzIpbjoyGDcg=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="9EqGrD8oaYRaIUcF444JJA=="/>
  </form>
  <processNote>
    <number value="11"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="print"/>
        <display value="Print (Form)"/>
        <userSelected value="false"/>
      </coding>
      <text value="2o5BYGTtOGrbmfCLi0R0sA=="/>
    </type>
    <text value="AcjIo9nLqALmg4BJYqA5fQ=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="hr"/>
        <display value="Kroatisk"/>
        <userSelected value="false"/>
      </coding>
      <text value="jrN3ATqyj77kjSa6YDQIjQ=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="vision"/>
        <display value="Vision Health Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="x5rBc+Ed4+STLUJu2UwALA=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="F4"/>
        <display value="Hearing Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="oZEAOnjfEAMgGmXa724K6w=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="SisG1mJd0vFq9zIHp8kSeg=="/>
    <description value="TuTm+CXXmVbX9jIv8LIG9A=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="in"/>
        <display value="In Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="MixNMNduNhjsZVdFG8ZKaQ=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="individual"/>
        <display value="Individual"/>
        <userSelected value="false"/>
      </coding>
      <text value="JMxwttxkHikjrxbC2VQY7A=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="lifetime"/>
        <display value="Lifetime"/>
        <userSelected value="true"/>
      </coding>
      <text value="SLv42q7xrs3OoN6HTduYVg=="/>
    </term>
    <financial>
      <type>
        <text value="xaOJ/GJrqS/4+f+YeZykYw=="/>
      </type>
      <allowedMoney>
        <value value="0.11653396525216353"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </allowedMoney>
      <usedMoney>
        <value value="0.7675381243575978"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

nil?

nil?

ExplanationOfBenefit "11" Version "2"

Updated by ANONYMOUS (Unknown) at 10/16/2017 6:22:12 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

+GVmczQdWByik7+AEa5wmA==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="11"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2017-10-16T06:22:12Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="fy"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">+GVmczQdWByik7+AEa5wmA==</div>
  </text>
  <identifier>
    <use value="usual"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/identifier-type"/>
        <code value="SNO"/>
        <display value="Serial Number"/>
        <userSelected value="false"/>
      </coding>
      <text value="R5dbfC6iuV+zfAIyB6gvMw=="/>
    </type>
    <system value="http://projectcrucible.org/r7cz7aoG/FX3PErmvyE0Xg=="/>
    <value value="4eDiTVsXygsX7GQRx208iA=="/>
    <period>
      <start value="2017-10-16T02:22:12.144Z"/>
      <end value="2017-10-16T02:22:12.144Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/l7ImwcTk8U305ITkhB30CA=="/>
        <value value="7ZzIT0urHLArhxiFFs182g=="/>
      </identifier>
      <display value="Organization AiWtP0xKOU+xualiX9SbcQ=="/>
    </assigner>
  </identifier>
  <status value="cancelled"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="pharmacy"/>
      <display value="Pharmacy"/>
      <userSelected value="true"/>
    </coding>
    <text value="2V9cHztrsOg06BqXRX4Z1Q=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="emergency"/>
      <display value="Emergency Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="4+PwyufJ+KHk81Byw4pRWQ=="/>
  </subType>
  <patient>
    <identifier>
      <use value="official"/>
      <type>
        <text value="aNZraJ0/LVZpAhnsSHjkjA=="/>
      </type>
      <system value="http://projectcrucible.org/rB50N5WrUFB/tyYyDbvOZw=="/>
      <value value="FvLXB8pFVt1lz/XdtXkYiw=="/>
      <period>
        <start value="2017-10-16T02:22:12.147Z"/>
        <end value="2017-10-16T02:22:12.147Z"/>
      </period>
      <assigner>
        <display value="Organization 81fPNHtAgWh5lDZHlauEuA=="/>
      </assigner>
    </identifier>
    <display value="Patient 570gItpRayDZxmjju6ePIA=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-16T02:22:12.147Z"/>
    <end value="2017-10-16T02:22:12.147Z"/>
  </billablePeriod>
  <created value="2017-10-16T02:22:12.692Z"/>
  <enterer>
    <identifier>
      <use value="official"/>
      <type>
        <text value="BergYGJ8qkQjxC0UyXKbdA=="/>
      </type>
      <system value="http://projectcrucible.org/0Q+VLIvOIPD+mBXHPe9uzQ=="/>
      <value value="hSecUm299O2MmGo7vpYNQQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.148Z"/>
        <end value="2017-10-16T02:22:12.148Z"/>
      </period>
      <assigner>
        <display value="Organization k4uPWV+fhLHxxHAi1IAEXg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner spmLJy/mEY1mTr/S4QOaVA=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="CE76ZK0lqPR1VVd67Y8AFg=="/>
      </type>
      <system value="http://projectcrucible.org/CHHMeVPX7Qb63iplYGcuow=="/>
      <value value="rK+Oa43QyhTXOoZ7iur3yg=="/>
      <period>
        <start value="2017-10-16T02:22:12.149Z"/>
        <end value="2017-10-16T02:22:12.149Z"/>
      </period>
      <assigner>
        <display value="Organization LXoqA9VLrPJXQjy746t0CQ=="/>
      </assigner>
    </identifier>
    <display value="Organization 4SLSlMswbbvIP4+gMwo4+g=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="official"/>
      <type>
        <text value="rquByVndQVj2ZSKKXqI41w=="/>
      </type>
      <system value="http://projectcrucible.org/S1tjwsDqJRvtx7/W2HFiiw=="/>
      <value value="Ry64vyKU70NJh11BGYq1cA=="/>
      <period>
        <start value="2017-10-16T02:22:12.149Z"/>
        <end value="2017-10-16T02:22:12.149Z"/>
      </period>
      <assigner>
        <display value="Organization 28fGHMftf+ItiShX8bnWJw=="/>
      </assigner>
    </identifier>
    <display value="Practitioner Xhs54k1IyWJuXcJ2ZZecZg=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="G8+VNChZUWtHKU5bqXsahg=="/>
      </type>
      <system value="http://projectcrucible.org/utEtvRjgqdhAR9HF9MMFpA=="/>
      <value value="dAfG6+IREg0cA5f1fm4A/A=="/>
      <period>
        <start value="2017-10-16T02:22:12.150Z"/>
        <end value="2017-10-16T02:22:12.150Z"/>
      </period>
      <assigner>
        <display value="Organization S/rmDo8FEpLoKH+qyRbztw=="/>
      </assigner>
    </identifier>
    <display value="Organization sYJvxPHSzYh6vSn6iFYxig=="/>
  </organization>
  <referral>
    <identifier>
      <use value="official"/>
      <type>
        <text value="2jvbXfEVpU6s0VHyB/G7mg=="/>
      </type>
      <system value="http://projectcrucible.org/PT2LCiROT21ALsPaav1tNA=="/>
      <value value="2YXOrCZOGw7FwWrJkihWCA=="/>
      <period>
        <start value="2017-10-16T02:22:12.151Z"/>
        <end value="2017-10-16T02:22:12.151Z"/>
      </period>
      <assigner>
        <display value="Organization GyMTMhthZiH2n3LxspqUjg=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest m4xCp/f5QS91dFYTBS7rqQ=="/>
  </referral>
  <facility>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="m4I+d1YAz1BI7XUgI6sxDg=="/>
      </type>
      <system value="http://projectcrucible.org/fyIeY4dYTahmuE9HMZuOWA=="/>
      <value value="Tuwl9C6/wX2W/YJmYlebZg=="/>
      <period>
        <start value="2017-10-16T02:22:12.151Z"/>
        <end value="2017-10-16T02:22:12.151Z"/>
      </period>
      <assigner>
        <display value="Organization Xnojw53My0mB0HnNuujrww=="/>
      </assigner>
    </identifier>
    <display value="Location s41Vc22Y7atxNLavlVcwCw=="/>
  </facility>
  <claim>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="BzYMN0ofR1xCzolX3BT1yg=="/>
      </type>
      <system value="http://projectcrucible.org/i8CU9J+MPElNO6OXZt2EEg=="/>
      <value value="c5/DeofV5ms389bTjFusUA=="/>
      <period>
        <start value="2017-10-16T02:22:12.152Z"/>
        <end value="2017-10-16T02:22:12.152Z"/>
      </period>
      <assigner>
        <display value="Organization v91ODQ79sY/Yh+sDcz7G4A=="/>
      </assigner>
    </identifier>
    <display value="Claim PwYaAUcqHmHxrizhSCCx8Q=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="pqw/4xrj70LBpFHM0UKgow=="/>
      </type>
      <system value="http://projectcrucible.org/NNobAu5yJ7ufAaSmZfi4Cg=="/>
      <value value="uoSNofFXkgG9G+HCYBrOBQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.153Z"/>
        <end value="2017-10-16T02:22:12.153Z"/>
      </period>
      <assigner>
        <display value="Organization E0luuAISP8tlNI0jufNL+w=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse 9lTM4q54PyqPPIyPqIVnbg=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="error"/>
      <display value="Error"/>
      <userSelected value="true"/>
    </coding>
    <text value="OOfrCNiDoaCo/ZV0sVvsIQ=="/>
  </outcome>
  <disposition value="dB2ubB7CgRBeWumbbVEC3w=="/>
  <related>
    <claim>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/6uhvDqRbFXfVdmU8upfnGg=="/>
        <value value="EZbb0ho+2N5LbiUSM6rc7A=="/>
      </identifier>
      <display value="Claim kYVcB19jAMOIP4Lz4y3cuQ=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="E0j1EoXkVAiVtVuIoZysWA=="/>
    </relationship>
    <reference>
      <use value="usual"/>
      <type>
        <text value="zP8XDNgVPXsPfEkicJhcVQ=="/>
      </type>
      <system value="http://projectcrucible.org/40stipFRvQOnupwasJcsuA=="/>
      <value value="6nJZS0dqAfoookHX2PYH4A=="/>
      <period>
        <start value="2017-10-16T02:22:12.157Z"/>
        <end value="2017-10-16T02:22:12.157Z"/>
      </period>
      <assigner>
        <display value="Organization HLsEA01uVAZ0WIlM5O43Lw=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="piWqcqVDbfx9aybk9lINog=="/>
      </type>
      <system value="http://projectcrucible.org/ThDiAmL5u+wbvv50Bx9uUg=="/>
      <value value="sT4RyFLVrQQrcUzoRdDMQQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.158Z"/>
        <end value="2017-10-16T02:22:12.158Z"/>
      </period>
      <assigner>
        <display value="Organization LzULbq7x4VUZ6mVkxG6z1g=="/>
      </assigner>
    </identifier>
    <display value="VisionPrescription dE6sU8LVt1dDFH+wzPAOhg=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="official"/>
      <type>
        <text value="LTfApVagaz9PIKnE2YwZqQ=="/>
      </type>
      <system value="http://projectcrucible.org/I+zd9pVHV3A2Rfl5JRBjHw=="/>
      <value value="JqDyClKrnRPPxqzmAhdcDA=="/>
      <period>
        <start value="2017-10-16T02:22:12.159Z"/>
        <end value="2017-10-16T02:22:12.159Z"/>
      </period>
      <assigner>
        <display value="Organization /VsyQqHthVWjJEY+IcWCrw=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest 9uO2+4+LV/4J3MnDGs2jOQ=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="+JeY2ZcnQtJ5PRJbrobMfg=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="relatedperson"/>
        <display value="RelatedPerson"/>
        <userSelected value="true"/>
      </coding>
      <text value="Dn1cHHv5nZ9tbPovikY9xQ=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/vX0dWVAZqSU3lsGemckYcA=="/>
        <value value="mtTtn4A6w2FFNynQkWr8+Q=="/>
      </identifier>
      <display value="RelatedPerson i7Xms1IykNbOcTf1Z1Jq/g=="/>
    </party>
  </payee>
  <information>
    <sequence value="51"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="onset"/>
        <display value="Onset"/>
        <userSelected value="false"/>
      </coding>
      <text value="ZY9ZzWVI5X1HvzJb7Yf8+Q=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="disabled"/>
        <display value="Disabled"/>
        <userSelected value="true"/>
      </coding>
      <text value="1YQmHkvyfoGH5rYQ7mQiDg=="/>
    </code>
    <timingDate value="2017-10-16"/>
    <valueReference>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/Xynl9gDaNkZVen6VfxKIaA=="/>
        <value value="JiPq0WIdgjCbJQ0TNoR6gg=="/>
      </identifier>
      <display value="Resource S2hST1up63EkNxENUdXvGQ=="/>
    </valueReference>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="e"/>
      <display value="E"/>
      <userSelected value="true"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="6"/>
    <provider>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/i53Hmz+1Al5CgfcKCVPQOw=="/>
        <value value="G4YzlG68qI5/dXkxbBLyCw=="/>
      </identifier>
      <display value="Organization PI/O8ej3iuxsoHpXlawa+Q=="/>
    </provider>
    <responsible value="true"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="supervisor"/>
        <display value="Supervising Provider"/>
        <userSelected value="true"/>
      </coding>
      <text value="0e58cbLten3J9MQMaMmEIw=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="false"/>
      </coding>
      <text value="0VoTQyvhqEbN1nApefRKgg=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="52"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/mEDMxr46xymyC+4xgiEkhQ=="/>
        <code value="JgDKJjG3JHE4YmTRt88QFQ=="/>
        <display value="VTYYdUb6bCFpzso6+Dzfcg=="/>
        <userSelected value="true"/>
      </coding>
      <text value="hN/cId1GBa9Zmz42OpUfkA=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="nursing"/>
        <display value="Nursing Diagnosis"/>
        <userSelected value="true"/>
      </coding>
      <text value="edhEWghYkzRh3PF9WcfDeA=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="100"/>
        <display value="Normal Vaginal Delivery"/>
        <userSelected value="true"/>
      </coding>
      <text value="esZLe38I+G5YgBgx3NVp/w=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="56"/>
    <date value="2017-10-16T02:22:12.173Z"/>
    <procedureReference>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/mBsqhZ8T+Wm0lcaX4OQDQQ=="/>
        <value value="8AXOwYPGuOw5uGZB19V82Q=="/>
      </identifier>
      <display value="Procedure rX1cC5bJodwWMNNBwBPAGw=="/>
    </procedureReference>
  </procedure>
  <precedence value="35"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/0LHUElZyXKcpwY0pSd/7KA=="/>
        <value value="E7v2zpDEFpX3DupzyRxiLg=="/>
      </identifier>
      <display value="Coverage kdmaRIAlJn5Vr6ImKU8boQ=="/>
    </coverage>
    <preAuthRef value="z9oVA+1XyCBtA33dOscG0A=="/>
  </insurance>
  <accident>
    <date value="2017-10-16"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="MVA"/>
        <display value="Motor vehicle accident"/>
        <userSelected value="false"/>
      </coding>
      <text value="M27wYbAlP8Dtsojho+Jp5w=="/>
    </type>
    <locationAddress>
      <use value="home"/>
      <type value="postal"/>
      <text value="M7ohJ4Ow4Jq7Rfsi0UpgZA=="/>
      <line value="642o9EcIUwBgMDr3tbnZJA=="/>
      <city value="IPREKpCzqkDplStWiURcXg=="/>
      <district value="XRaKIE+lnvfsh7oX5j2TQA=="/>
      <state value="AitWbyS92iEqyW0hhMVvrA=="/>
      <postalCode value="3oipcgb9UgemTjMFbO4w8Q=="/>
      <country value="9jUq39//aTMcow0B4WJBeA=="/>
      <period>
        <start value="2017-10-16T02:22:12.176Z"/>
        <end value="2017-10-16T02:22:12.176Z"/>
      </period>
    </locationAddress>
  </accident>
  <employmentImpacted>
    <start value="2017-10-16T02:22:12.176Z"/>
    <end value="2017-10-16T02:22:12.176Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-16T02:22:12.176Z"/>
    <end value="2017-10-16T02:22:12.176Z"/>
  </hospitalization>
  <item>
    <sequence value="67"/>
    <careTeamLinkId value="26"/>
    <diagnosisLinkId value="19"/>
    <procedureLinkId value="81"/>
    <informationLinkId value="60"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0440"/>
        <display value="Speech-Language Pathology"/>
        <userSelected value="true"/>
      </coding>
      <text value="gsbgUeHLDf1JTCUQvTQYOQ=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="1"/>
        <display value="Medical Care"/>
        <userSelected value="false"/>
      </coding>
      <text value="jdFwxah/RUb9/cIteZr3Lw=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="2141"/>
        <display value="Radiograph, bytewing"/>
        <userSelected value="true"/>
      </coding>
      <text value="owVcYY2VfDsKODzNCTR+4A=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="jHyG/tlhbhzphOFYppX5Sw=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="as"/>
        <display value="Child Asthma"/>
        <userSelected value="false"/>
      </coding>
      <text value="mYc70gSNOK7sFueyPHDfrA=="/>
    </programCode>
    <servicedPeriod>
      <start value="2017-10-16T02:22:12.184Z"/>
      <end value="2017-10-16T02:22:12.184Z"/>
    </servicedPeriod>
    <locationReference>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/pbyI9cDJFtzf7uBUAoDayg=="/>
        <value value="Emiz4W9Nx69nLSaqIHIQrg=="/>
      </identifier>
      <display value="Location Tu9VUnYvZtMqGKSW/QBlIg=="/>
    </locationReference>
    <quantity>
      <value value="0.4307687758574208"/>
      <unit value="jTPQ+xSkJFR4dHHstMfVTg=="/>
      <system value="http://projectcrucible.org/CmFP4BjoBCKuV0vBU1RqKw=="/>
      <code value="ascJTY4ZJxD5/fJw5GNjAg=="/>
    </quantity>
    <unitPrice>
      <value value="0.4418826372646052"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.12115892477512091"/>
    <net>
      <value value="0.795869482215034"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/ib53DWqatUwEop4cEqegiA=="/>
        <value value="Ygw2u0VddoKi2kHihrhPpA=="/>
      </identifier>
      <display value="Device KyBoEdddjnTyoXI1CIWUvg=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="11"/>
        <display value="11"/>
        <userSelected value="true"/>
      </coding>
      <text value="VPgmqprC9GZlMKqKCxrF+A=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="D"/>
        <display value="Distal"/>
        <userSelected value="true"/>
      </coding>
      <text value="o1lu5fzz79pP2uFPo5T9Bw=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/cq6J7xDStE4rOalXsJVMdw=="/>
        <value value="adYosCRkp6nt9aZGpmlNcw=="/>
      </identifier>
      <display value="Encounter BwrqjRms4I7OzSAdsiGuUw=="/>
    </encounter>
    <noteNumber value="13"/>
    <adjudication>
      <category>
        <text value="4h6j7PYvjDsR7TW/FwTbVQ=="/>
      </category>
      <reason>
        <text value="qzRP9XU9AWpV0VRWn+c+tA=="/>
      </reason>
      <amount>
        <value value="0.550228184825771"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.5735388523021192"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="83"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0421"/>
        <display value="Physical Therapy -"/>
        <userSelected value="false"/>
      </coding>
      <text value="VLIs9w5MRDabtfrh9XLpPg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="62"/>
        <display value="MRI Scan"/>
        <userSelected value="false"/>
      </coding>
      <text value="z5zrCtV03LEfBl/Hzd2cDQ=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1101"/>
        <display value="Exam, comp, primary"/>
        <userSelected value="true"/>
      </coding>
      <text value="pLZB9rWDSXY2ts1zyG3IZQ=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="rooh"/>
        <display value="Rush or Outside of office hours"/>
        <userSelected value="true"/>
      </coding>
      <text value="e6skiyEaZZm19nnROfsa2A=="/>
    </modifier>
    <fee>
      <value value="0.300208174277664"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="81"/>
    <adjudication>
      <category>
        <text value="Mait/mNAi/T3tvz9MoLSQw=="/>
      </category>
      <reason>
        <text value="4QVrghUqq/Ahwp9jSUBG9g=="/>
      </reason>
      <amount>
        <value value="0.540422738893876"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.6425992315769833"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.3435676794524314"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.4004948101971606"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.2327116237735245"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="partial"/>
        <display value="Partial"/>
        <userSelected value="true"/>
      </coding>
      <text value="DcCc0Cc+ritOMMVBk+b+RQ=="/>
    </type>
    <adjustment>
      <value value="0.18215146386220848"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a001"/>
        <display value="Prior Payment Reversal"/>
        <userSelected value="false"/>
      </coding>
      <text value="+ZZkpNJuc0YqWwt0xWStmQ=="/>
    </adjustmentReason>
    <date value="2017-10-16"/>
    <amount>
      <value value="0.8835708352269088"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="Re7NFKmNQPXVeeWncyy2rg=="/>
      </type>
      <system value="http://projectcrucible.org/g68tqzBMRBHOV8mqYefIVA=="/>
      <value value="nW1uDjqBzEMsRAN694rrCg=="/>
      <period>
        <start value="2017-10-16T02:22:12.199Z"/>
        <end value="2017-10-16T02:22:12.199Z"/>
      </period>
      <assigner>
        <display value="Organization vzDIDFSCPQc5I1h2yADcdA=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="THAxciwnSOVts6ebiWlDmg=="/>
  </form>
  <processNote>
    <number value="99"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="printoper"/>
        <display value="Print (Operator)"/>
        <userSelected value="false"/>
      </coding>
      <text value="ksgS59F07M4QpFAhFqIpTg=="/>
    </type>
    <text value="7EQeEJdj9jYMvRH4JJ1UEg=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="fr-CH"/>
        <display value="Fransk (Schweiz)"/>
        <userSelected value="true"/>
      </coding>
      <text value="p57xBhiC0qJoflw+zQsDnQ=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="vision"/>
        <display value="Vision Health Coverage"/>
        <userSelected value="false"/>
      </coding>
      <text value="HmYMZZzv/wHKDSGRWeyHrQ=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="76"/>
        <display value="Renal Dialysis"/>
        <userSelected value="false"/>
      </coding>
      <text value="o2EmZ6Jgr9sMTOAEsVEVLg=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="a6IG7a46TbwgWkMoZSqJhA=="/>
    <description value="f1Hp+1Xr7jG5ESv7SmbNbg=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="out"/>
        <display value="Out of Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="jefUIVDF4xX35rGA5IIGxg=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="family"/>
        <display value="Family"/>
        <userSelected value="true"/>
      </coding>
      <text value="/7cGkVr2NtuWkbXb/T4Y2w=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="lifetime"/>
        <display value="Lifetime"/>
        <userSelected value="true"/>
      </coding>
      <text value="6VkdsT2U0vtHKtE7W4CCTA=="/>
    </term>
    <financial>
      <type>
        <text value="MFvxNBZdmdWiMsPia4uU7Q=="/>
      </type>
      <allowedUnsignedInt value="98"/>
      <usedUnsignedInt value="99"/>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

ExplanationOfBenefit "11" Version "1"

Created by ANONYMOUS (Unknown) at 10/16/2017 6:22:12 AM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

+GVmczQdWByik7+AEa5wmA==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="11"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-10-16T06:22:12Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="te"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">+GVmczQdWByik7+AEa5wmA==</div>
  </text>
  <identifier>
    <use value="usual"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/identifier-type"/>
        <code value="SNO"/>
        <display value="Serial Number"/>
        <userSelected value="false"/>
      </coding>
      <text value="R5dbfC6iuV+zfAIyB6gvMw=="/>
    </type>
    <system value="http://projectcrucible.org/r7cz7aoG/FX3PErmvyE0Xg=="/>
    <value value="4eDiTVsXygsX7GQRx208iA=="/>
    <period>
      <start value="2017-10-16T02:22:12.144Z"/>
      <end value="2017-10-16T02:22:12.144Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/l7ImwcTk8U305ITkhB30CA=="/>
        <value value="7ZzIT0urHLArhxiFFs182g=="/>
      </identifier>
      <display value="Organization AiWtP0xKOU+xualiX9SbcQ=="/>
    </assigner>
  </identifier>
  <status value="entered-in-error"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="pharmacy"/>
      <display value="Pharmacy"/>
      <userSelected value="true"/>
    </coding>
    <text value="2V9cHztrsOg06BqXRX4Z1Q=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="emergency"/>
      <display value="Emergency Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="4+PwyufJ+KHk81Byw4pRWQ=="/>
  </subType>
  <patient>
    <identifier>
      <use value="official"/>
      <type>
        <text value="aNZraJ0/LVZpAhnsSHjkjA=="/>
      </type>
      <system value="http://projectcrucible.org/rB50N5WrUFB/tyYyDbvOZw=="/>
      <value value="FvLXB8pFVt1lz/XdtXkYiw=="/>
      <period>
        <start value="2017-10-16T02:22:12.147Z"/>
        <end value="2017-10-16T02:22:12.147Z"/>
      </period>
      <assigner>
        <display value="Organization 81fPNHtAgWh5lDZHlauEuA=="/>
      </assigner>
    </identifier>
    <display value="Patient 570gItpRayDZxmjju6ePIA=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-16T02:22:12.147Z"/>
    <end value="2017-10-16T02:22:12.147Z"/>
  </billablePeriod>
  <created value="2017-10-16T02:22:12.147Z"/>
  <enterer>
    <identifier>
      <use value="official"/>
      <type>
        <text value="BergYGJ8qkQjxC0UyXKbdA=="/>
      </type>
      <system value="http://projectcrucible.org/0Q+VLIvOIPD+mBXHPe9uzQ=="/>
      <value value="hSecUm299O2MmGo7vpYNQQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.148Z"/>
        <end value="2017-10-16T02:22:12.148Z"/>
      </period>
      <assigner>
        <display value="Organization k4uPWV+fhLHxxHAi1IAEXg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner spmLJy/mEY1mTr/S4QOaVA=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="CE76ZK0lqPR1VVd67Y8AFg=="/>
      </type>
      <system value="http://projectcrucible.org/CHHMeVPX7Qb63iplYGcuow=="/>
      <value value="rK+Oa43QyhTXOoZ7iur3yg=="/>
      <period>
        <start value="2017-10-16T02:22:12.149Z"/>
        <end value="2017-10-16T02:22:12.149Z"/>
      </period>
      <assigner>
        <display value="Organization LXoqA9VLrPJXQjy746t0CQ=="/>
      </assigner>
    </identifier>
    <display value="Organization 4SLSlMswbbvIP4+gMwo4+g=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="official"/>
      <type>
        <text value="rquByVndQVj2ZSKKXqI41w=="/>
      </type>
      <system value="http://projectcrucible.org/S1tjwsDqJRvtx7/W2HFiiw=="/>
      <value value="Ry64vyKU70NJh11BGYq1cA=="/>
      <period>
        <start value="2017-10-16T02:22:12.149Z"/>
        <end value="2017-10-16T02:22:12.149Z"/>
      </period>
      <assigner>
        <display value="Organization 28fGHMftf+ItiShX8bnWJw=="/>
      </assigner>
    </identifier>
    <display value="Practitioner Xhs54k1IyWJuXcJ2ZZecZg=="/>
  </provider>
  <organization>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="G8+VNChZUWtHKU5bqXsahg=="/>
      </type>
      <system value="http://projectcrucible.org/utEtvRjgqdhAR9HF9MMFpA=="/>
      <value value="dAfG6+IREg0cA5f1fm4A/A=="/>
      <period>
        <start value="2017-10-16T02:22:12.150Z"/>
        <end value="2017-10-16T02:22:12.150Z"/>
      </period>
      <assigner>
        <display value="Organization S/rmDo8FEpLoKH+qyRbztw=="/>
      </assigner>
    </identifier>
    <display value="Organization sYJvxPHSzYh6vSn6iFYxig=="/>
  </organization>
  <referral>
    <identifier>
      <use value="official"/>
      <type>
        <text value="2jvbXfEVpU6s0VHyB/G7mg=="/>
      </type>
      <system value="http://projectcrucible.org/PT2LCiROT21ALsPaav1tNA=="/>
      <value value="2YXOrCZOGw7FwWrJkihWCA=="/>
      <period>
        <start value="2017-10-16T02:22:12.151Z"/>
        <end value="2017-10-16T02:22:12.151Z"/>
      </period>
      <assigner>
        <display value="Organization GyMTMhthZiH2n3LxspqUjg=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest m4xCp/f5QS91dFYTBS7rqQ=="/>
  </referral>
  <facility>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="m4I+d1YAz1BI7XUgI6sxDg=="/>
      </type>
      <system value="http://projectcrucible.org/fyIeY4dYTahmuE9HMZuOWA=="/>
      <value value="Tuwl9C6/wX2W/YJmYlebZg=="/>
      <period>
        <start value="2017-10-16T02:22:12.151Z"/>
        <end value="2017-10-16T02:22:12.151Z"/>
      </period>
      <assigner>
        <display value="Organization Xnojw53My0mB0HnNuujrww=="/>
      </assigner>
    </identifier>
    <display value="Location s41Vc22Y7atxNLavlVcwCw=="/>
  </facility>
  <claim>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="BzYMN0ofR1xCzolX3BT1yg=="/>
      </type>
      <system value="http://projectcrucible.org/i8CU9J+MPElNO6OXZt2EEg=="/>
      <value value="c5/DeofV5ms389bTjFusUA=="/>
      <period>
        <start value="2017-10-16T02:22:12.152Z"/>
        <end value="2017-10-16T02:22:12.152Z"/>
      </period>
      <assigner>
        <display value="Organization v91ODQ79sY/Yh+sDcz7G4A=="/>
      </assigner>
    </identifier>
    <display value="Claim PwYaAUcqHmHxrizhSCCx8Q=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="pqw/4xrj70LBpFHM0UKgow=="/>
      </type>
      <system value="http://projectcrucible.org/NNobAu5yJ7ufAaSmZfi4Cg=="/>
      <value value="uoSNofFXkgG9G+HCYBrOBQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.153Z"/>
        <end value="2017-10-16T02:22:12.153Z"/>
      </period>
      <assigner>
        <display value="Organization E0luuAISP8tlNI0jufNL+w=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse 9lTM4q54PyqPPIyPqIVnbg=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="error"/>
      <display value="Error"/>
      <userSelected value="true"/>
    </coding>
    <text value="OOfrCNiDoaCo/ZV0sVvsIQ=="/>
  </outcome>
  <disposition value="jQk2ybb4GZvLOacU3lhdJA=="/>
  <related>
    <claim>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/6uhvDqRbFXfVdmU8upfnGg=="/>
        <value value="EZbb0ho+2N5LbiUSM6rc7A=="/>
      </identifier>
      <display value="Claim kYVcB19jAMOIP4Lz4y3cuQ=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="false"/>
      </coding>
      <text value="E0j1EoXkVAiVtVuIoZysWA=="/>
    </relationship>
    <reference>
      <use value="usual"/>
      <type>
        <text value="zP8XDNgVPXsPfEkicJhcVQ=="/>
      </type>
      <system value="http://projectcrucible.org/40stipFRvQOnupwasJcsuA=="/>
      <value value="6nJZS0dqAfoookHX2PYH4A=="/>
      <period>
        <start value="2017-10-16T02:22:12.157Z"/>
        <end value="2017-10-16T02:22:12.157Z"/>
      </period>
      <assigner>
        <display value="Organization HLsEA01uVAZ0WIlM5O43Lw=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="piWqcqVDbfx9aybk9lINog=="/>
      </type>
      <system value="http://projectcrucible.org/ThDiAmL5u+wbvv50Bx9uUg=="/>
      <value value="sT4RyFLVrQQrcUzoRdDMQQ=="/>
      <period>
        <start value="2017-10-16T02:22:12.158Z"/>
        <end value="2017-10-16T02:22:12.158Z"/>
      </period>
      <assigner>
        <display value="Organization LzULbq7x4VUZ6mVkxG6z1g=="/>
      </assigner>
    </identifier>
    <display value="VisionPrescription dE6sU8LVt1dDFH+wzPAOhg=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="official"/>
      <type>
        <text value="LTfApVagaz9PIKnE2YwZqQ=="/>
      </type>
      <system value="http://projectcrucible.org/I+zd9pVHV3A2Rfl5JRBjHw=="/>
      <value value="JqDyClKrnRPPxqzmAhdcDA=="/>
      <period>
        <start value="2017-10-16T02:22:12.159Z"/>
        <end value="2017-10-16T02:22:12.159Z"/>
      </period>
      <assigner>
        <display value="Organization /VsyQqHthVWjJEY+IcWCrw=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest 9uO2+4+LV/4J3MnDGs2jOQ=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
        <userSelected value="false"/>
      </coding>
      <text value="+JeY2ZcnQtJ5PRJbrobMfg=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="relatedperson"/>
        <display value="RelatedPerson"/>
        <userSelected value="true"/>
      </coding>
      <text value="Dn1cHHv5nZ9tbPovikY9xQ=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/vX0dWVAZqSU3lsGemckYcA=="/>
        <value value="mtTtn4A6w2FFNynQkWr8+Q=="/>
      </identifier>
      <display value="RelatedPerson i7Xms1IykNbOcTf1Z1Jq/g=="/>
    </party>
  </payee>
  <information>
    <sequence value="51"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="onset"/>
        <display value="Onset"/>
        <userSelected value="false"/>
      </coding>
      <text value="ZY9ZzWVI5X1HvzJb7Yf8+Q=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="disabled"/>
        <display value="Disabled"/>
        <userSelected value="true"/>
      </coding>
      <text value="1YQmHkvyfoGH5rYQ7mQiDg=="/>
    </code>
    <timingDate value="2017-10-16"/>
    <valueReference>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/Xynl9gDaNkZVen6VfxKIaA=="/>
        <value value="JiPq0WIdgjCbJQ0TNoR6gg=="/>
      </identifier>
      <display value="Resource S2hST1up63EkNxENUdXvGQ=="/>
    </valueReference>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="e"/>
      <display value="E"/>
      <userSelected value="true"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="6"/>
    <provider>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/i53Hmz+1Al5CgfcKCVPQOw=="/>
        <value value="G4YzlG68qI5/dXkxbBLyCw=="/>
      </identifier>
      <display value="Organization PI/O8ej3iuxsoHpXlawa+Q=="/>
    </provider>
    <responsible value="true"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="supervisor"/>
        <display value="Supervising Provider"/>
        <userSelected value="true"/>
      </coding>
      <text value="0e58cbLten3J9MQMaMmEIw=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="false"/>
      </coding>
      <text value="0VoTQyvhqEbN1nApefRKgg=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="52"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/mEDMxr46xymyC+4xgiEkhQ=="/>
        <code value="JgDKJjG3JHE4YmTRt88QFQ=="/>
        <display value="VTYYdUb6bCFpzso6+Dzfcg=="/>
        <userSelected value="true"/>
      </coding>
      <text value="hN/cId1GBa9Zmz42OpUfkA=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="nursing"/>
        <display value="Nursing Diagnosis"/>
        <userSelected value="true"/>
      </coding>
      <text value="edhEWghYkzRh3PF9WcfDeA=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="100"/>
        <display value="Normal Vaginal Delivery"/>
        <userSelected value="true"/>
      </coding>
      <text value="esZLe38I+G5YgBgx3NVp/w=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="56"/>
    <date value="2017-10-16T02:22:12.173Z"/>
    <procedureReference>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/mBsqhZ8T+Wm0lcaX4OQDQQ=="/>
        <value value="8AXOwYPGuOw5uGZB19V82Q=="/>
      </identifier>
      <display value="Procedure rX1cC5bJodwWMNNBwBPAGw=="/>
    </procedureReference>
  </procedure>
  <precedence value="72"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/0LHUElZyXKcpwY0pSd/7KA=="/>
        <value value="E7v2zpDEFpX3DupzyRxiLg=="/>
      </identifier>
      <display value="Coverage kdmaRIAlJn5Vr6ImKU8boQ=="/>
    </coverage>
    <preAuthRef value="z9oVA+1XyCBtA33dOscG0A=="/>
  </insurance>
  <accident>
    <date value="2017-10-16"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="MVA"/>
        <display value="Motor vehicle accident"/>
        <userSelected value="false"/>
      </coding>
      <text value="M27wYbAlP8Dtsojho+Jp5w=="/>
    </type>
    <locationAddress>
      <use value="home"/>
      <type value="postal"/>
      <text value="M7ohJ4Ow4Jq7Rfsi0UpgZA=="/>
      <line value="642o9EcIUwBgMDr3tbnZJA=="/>
      <city value="IPREKpCzqkDplStWiURcXg=="/>
      <district value="XRaKIE+lnvfsh7oX5j2TQA=="/>
      <state value="AitWbyS92iEqyW0hhMVvrA=="/>
      <postalCode value="3oipcgb9UgemTjMFbO4w8Q=="/>
      <country value="9jUq39//aTMcow0B4WJBeA=="/>
      <period>
        <start value="2017-10-16T02:22:12.176Z"/>
        <end value="2017-10-16T02:22:12.176Z"/>
      </period>
    </locationAddress>
  </accident>
  <employmentImpacted>
    <start value="2017-10-16T02:22:12.176Z"/>
    <end value="2017-10-16T02:22:12.176Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-16T02:22:12.176Z"/>
    <end value="2017-10-16T02:22:12.176Z"/>
  </hospitalization>
  <item>
    <sequence value="67"/>
    <careTeamLinkId value="26"/>
    <diagnosisLinkId value="19"/>
    <procedureLinkId value="81"/>
    <informationLinkId value="60"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0440"/>
        <display value="Speech-Language Pathology"/>
        <userSelected value="true"/>
      </coding>
      <text value="gsbgUeHLDf1JTCUQvTQYOQ=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="1"/>
        <display value="Medical Care"/>
        <userSelected value="false"/>
      </coding>
      <text value="jdFwxah/RUb9/cIteZr3Lw=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="2141"/>
        <display value="Radiograph, bytewing"/>
        <userSelected value="true"/>
      </coding>
      <text value="owVcYY2VfDsKODzNCTR+4A=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="a"/>
        <display value="Repair of prior service or installation"/>
        <userSelected value="false"/>
      </coding>
      <text value="jHyG/tlhbhzphOFYppX5Sw=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="as"/>
        <display value="Child Asthma"/>
        <userSelected value="false"/>
      </coding>
      <text value="mYc70gSNOK7sFueyPHDfrA=="/>
    </programCode>
    <servicedPeriod>
      <start value="2017-10-16T02:22:12.184Z"/>
      <end value="2017-10-16T02:22:12.184Z"/>
    </servicedPeriod>
    <locationReference>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/pbyI9cDJFtzf7uBUAoDayg=="/>
        <value value="Emiz4W9Nx69nLSaqIHIQrg=="/>
      </identifier>
      <display value="Location Tu9VUnYvZtMqGKSW/QBlIg=="/>
    </locationReference>
    <quantity>
      <value value="0.4307687758574208"/>
      <unit value="jTPQ+xSkJFR4dHHstMfVTg=="/>
      <system value="http://projectcrucible.org/CmFP4BjoBCKuV0vBU1RqKw=="/>
      <code value="ascJTY4ZJxD5/fJw5GNjAg=="/>
    </quantity>
    <unitPrice>
      <value value="0.4418826372646052"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.12115892477512091"/>
    <net>
      <value value="0.795869482215034"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/ib53DWqatUwEop4cEqegiA=="/>
        <value value="Ygw2u0VddoKi2kHihrhPpA=="/>
      </identifier>
      <display value="Device KyBoEdddjnTyoXI1CIWUvg=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="11"/>
        <display value="11"/>
        <userSelected value="true"/>
      </coding>
      <text value="VPgmqprC9GZlMKqKCxrF+A=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="D"/>
        <display value="Distal"/>
        <userSelected value="true"/>
      </coding>
      <text value="o1lu5fzz79pP2uFPo5T9Bw=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/cq6J7xDStE4rOalXsJVMdw=="/>
        <value value="adYosCRkp6nt9aZGpmlNcw=="/>
      </identifier>
      <display value="Encounter BwrqjRms4I7OzSAdsiGuUw=="/>
    </encounter>
    <noteNumber value="13"/>
    <adjudication>
      <category>
        <text value="4h6j7PYvjDsR7TW/FwTbVQ=="/>
      </category>
      <reason>
        <text value="qzRP9XU9AWpV0VRWn+c+tA=="/>
      </reason>
      <amount>
        <value value="0.550228184825771"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.5735388523021192"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="83"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0421"/>
        <display value="Physical Therapy -"/>
        <userSelected value="false"/>
      </coding>
      <text value="VLIs9w5MRDabtfrh9XLpPg=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="62"/>
        <display value="MRI Scan"/>
        <userSelected value="false"/>
      </coding>
      <text value="z5zrCtV03LEfBl/Hzd2cDQ=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1101"/>
        <display value="Exam, comp, primary"/>
        <userSelected value="true"/>
      </coding>
      <text value="pLZB9rWDSXY2ts1zyG3IZQ=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="rooh"/>
        <display value="Rush or Outside of office hours"/>
        <userSelected value="true"/>
      </coding>
      <text value="e6skiyEaZZm19nnROfsa2A=="/>
    </modifier>
    <fee>
      <value value="0.300208174277664"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="81"/>
    <adjudication>
      <category>
        <text value="Mait/mNAi/T3tvz9MoLSQw=="/>
      </category>
      <reason>
        <text value="4QVrghUqq/Ahwp9jSUBG9g=="/>
      </reason>
      <amount>
        <value value="0.540422738893876"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.6425992315769833"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.3435676794524314"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.4004948101971606"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.2327116237735245"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="partial"/>
        <display value="Partial"/>
        <userSelected value="true"/>
      </coding>
      <text value="DcCc0Cc+ritOMMVBk+b+RQ=="/>
    </type>
    <adjustment>
      <value value="0.18215146386220848"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a001"/>
        <display value="Prior Payment Reversal"/>
        <userSelected value="false"/>
      </coding>
      <text value="+ZZkpNJuc0YqWwt0xWStmQ=="/>
    </adjustmentReason>
    <date value="2017-10-16"/>
    <amount>
      <value value="0.8835708352269088"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="Re7NFKmNQPXVeeWncyy2rg=="/>
      </type>
      <system value="http://projectcrucible.org/g68tqzBMRBHOV8mqYefIVA=="/>
      <value value="nW1uDjqBzEMsRAN694rrCg=="/>
      <period>
        <start value="2017-10-16T02:22:12.199Z"/>
        <end value="2017-10-16T02:22:12.199Z"/>
      </period>
      <assigner>
        <display value="Organization vzDIDFSCPQc5I1h2yADcdA=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="THAxciwnSOVts6ebiWlDmg=="/>
  </form>
  <processNote>
    <number value="99"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="printoper"/>
        <display value="Print (Operator)"/>
        <userSelected value="false"/>
      </coding>
      <text value="ksgS59F07M4QpFAhFqIpTg=="/>
    </type>
    <text value="7EQeEJdj9jYMvRH4JJ1UEg=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="fr-CH"/>
        <display value="Fransk (Schweiz)"/>
        <userSelected value="true"/>
      </coding>
      <text value="p57xBhiC0qJoflw+zQsDnQ=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="vision"/>
        <display value="Vision Health Coverage"/>
        <userSelected value="false"/>
      </coding>
      <text value="HmYMZZzv/wHKDSGRWeyHrQ=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="76"/>
        <display value="Renal Dialysis"/>
        <userSelected value="false"/>
      </coding>
      <text value="o2EmZ6Jgr9sMTOAEsVEVLg=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="a6IG7a46TbwgWkMoZSqJhA=="/>
    <description value="f1Hp+1Xr7jG5ESv7SmbNbg=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="out"/>
        <display value="Out of Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="jefUIVDF4xX35rGA5IIGxg=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="family"/>
        <display value="Family"/>
        <userSelected value="true"/>
      </coding>
      <text value="/7cGkVr2NtuWkbXb/T4Y2w=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="lifetime"/>
        <display value="Lifetime"/>
        <userSelected value="true"/>
      </coding>
      <text value="6VkdsT2U0vtHKtE7W4CCTA=="/>
    </term>
    <financial>
      <type>
        <text value="MFvxNBZdmdWiMsPia4uU7Q=="/>
      </type>
      <allowedUnsignedInt value="98"/>
      <usedUnsignedInt value="99"/>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

nil?

nil?

ExplanationOfBenefit "10" Version "2"

Updated by ANONYMOUS (Unknown) at 10/13/2017 6:09:09 AM(UTC)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

7Svqq0eB2L5szJKO69wUuQ==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="10"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2017-10-13T06:09:09Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="fr"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">7Svqq0eB2L5szJKO69wUuQ==</div>
  </text>
  <identifier>
    <use value="official"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/identifier-type"/>
        <code value="SNO"/>
        <display value="Serial Number"/>
        <userSelected value="false"/>
      </coding>
      <text value="HT+LgmAsq918k91VTq+msA=="/>
    </type>
    <system value="http://projectcrucible.org/9ZjasQyZ8oqiqCYCvTVw4Q=="/>
    <value value="MXOPNwU6CSK7rC93lxCTvg=="/>
    <period>
      <start value="2017-10-13T02:09:08.748Z"/>
      <end value="2017-10-13T02:09:08.748Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/XELn/Y2Gvb3EabxFYs7IJg=="/>
        <value value="H6+U8SuKR8zKCYfx6PXR7w=="/>
      </identifier>
      <display value="Organization HHKhoVHVYMBmnfaPL3fH3w=="/>
    </assigner>
  </identifier>
  <status value="entered-in-error"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="oral"/>
      <display value="Oral"/>
      <userSelected value="false"/>
    </coding>
    <text value="ZcF6LocgXO995EyclFNeFg=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="ortho"/>
      <display value="Orthodontic Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="GhTslkoXGb3dBABwbMaFXQ=="/>
  </subType>
  <patient>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="2RdlnTFj58IFXFgu2PMsnA=="/>
      </type>
      <system value="http://projectcrucible.org/TVo3+bW212ncqgQI9YKLGw=="/>
      <value value="kHlZ/9HLgGea/RhMullO4w=="/>
      <period>
        <start value="2017-10-13T02:09:08.751Z"/>
        <end value="2017-10-13T02:09:08.751Z"/>
      </period>
      <assigner>
        <display value="Organization csZi1sriYpAWPAHbP2F5eQ=="/>
      </assigner>
    </identifier>
    <display value="Patient mj6nVAAj3wZWVLP5vzR08Q=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-13T02:09:08.751Z"/>
    <end value="2017-10-13T02:09:08.751Z"/>
  </billablePeriod>
  <created value="2017-10-13T02:09:09.300Z"/>
  <enterer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="MI6NDUOCJf+8fG3U+qARog=="/>
      </type>
      <system value="http://projectcrucible.org/3qbINUv2VQ0hOis5A1uqxA=="/>
      <value value="Hz4ZLN5ce0ZjA09AM/yH/Q=="/>
      <period>
        <start value="2017-10-13T02:09:08.752Z"/>
        <end value="2017-10-13T02:09:08.752Z"/>
      </period>
      <assigner>
        <display value="Organization tDV0CyjECbsI3sY2yHYZ0w=="/>
      </assigner>
    </identifier>
    <display value="Practitioner AS8HKVY3pAUpPvX62tg5HQ=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="RA3TXjKxezQAEJ+MHUzPrQ=="/>
      </type>
      <system value="http://projectcrucible.org/OeIefPx7obCdcG9XQT3tYA=="/>
      <value value="6DJrirmqKS4nMEo12O+3LQ=="/>
      <period>
        <start value="2017-10-13T02:09:08.752Z"/>
        <end value="2017-10-13T02:09:08.752Z"/>
      </period>
      <assigner>
        <display value="Organization 2gwWttLu5vKoqKST/W/2xg=="/>
      </assigner>
    </identifier>
    <display value="Organization ORaUo7TSf65pcV63UbXxrA=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="s+RTFcNNt3gdKt5EqoXcBQ=="/>
      </type>
      <system value="http://projectcrucible.org/EsPGEVCEfXJypKtdogENfg=="/>
      <value value="evt5arNQ0DnxU5ngtyRJng=="/>
      <period>
        <start value="2017-10-13T02:09:08.756Z"/>
        <end value="2017-10-13T02:09:08.756Z"/>
      </period>
      <assigner>
        <display value="Organization itLHwDeaK1XM6IMbNePTFg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner PEeUwiTo1ImL6w4vN4CGAw=="/>
  </provider>
  <organization>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="osv1/kKgukbd9j/PzsgMcA=="/>
      </type>
      <system value="http://projectcrucible.org/p7CV40XF55j2FmtwLOU1PA=="/>
      <value value="NvCYCnTtGZPRTMJkfoVykw=="/>
      <period>
        <start value="2017-10-13T02:09:08.757Z"/>
        <end value="2017-10-13T02:09:08.757Z"/>
      </period>
      <assigner>
        <display value="Organization GXpHXnvAVaHf8LoNKGx4TQ=="/>
      </assigner>
    </identifier>
    <display value="Organization ytxHJUSw0bNApOUu4mazvQ=="/>
  </organization>
  <referral>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="NVzBVYY7rzSx7Mdhi2wfCA=="/>
      </type>
      <system value="http://projectcrucible.org/VNbbU+AyTv2z7WkzpzTW+Q=="/>
      <value value="ummFsK3Vc9lAFzllQd4MFA=="/>
      <period>
        <start value="2017-10-13T02:09:08.757Z"/>
        <end value="2017-10-13T02:09:08.757Z"/>
      </period>
      <assigner>
        <display value="Organization GBJivVHa91bHP6n+QsBlpg=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest KLn5H2Oo/40gMKylNjpy6Q=="/>
  </referral>
  <facility>
    <identifier>
      <use value="official"/>
      <type>
        <text value="2th8bnVxsVZ+ONxaUx9XBQ=="/>
      </type>
      <system value="http://projectcrucible.org/6Kcxa99sKj8dp9z3LhK2BA=="/>
      <value value="24LSansJoNIJngynqkdYjw=="/>
      <period>
        <start value="2017-10-13T02:09:08.758Z"/>
        <end value="2017-10-13T02:09:08.758Z"/>
      </period>
      <assigner>
        <display value="Organization LXHluN74wOOUzP2dLvxiIw=="/>
      </assigner>
    </identifier>
    <display value="Location bcYwtsLpPt0qGEjsZ1YZHw=="/>
  </facility>
  <claim>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="7HVP0VH5TyH0a9FWuAbE4g=="/>
      </type>
      <system value="http://projectcrucible.org/7RjeyCztEuCbS4vfVmb+vw=="/>
      <value value="/Qk4drKjZEPJlRB7g9hF0A=="/>
      <period>
        <start value="2017-10-13T02:09:08.758Z"/>
        <end value="2017-10-13T02:09:08.758Z"/>
      </period>
      <assigner>
        <display value="Organization 2G1tuW0uFmubmbe9Ynt89A=="/>
      </assigner>
    </identifier>
    <display value="Claim dU6PxoIXM+LS9Au+rRBiyg=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="rRrV7n8mqopZcSL7++iVkg=="/>
      </type>
      <system value="http://projectcrucible.org/Du+WqchJDEA/WLN+omYHlA=="/>
      <value value="oNuOU9RCuVUFVNVuGnnrFA=="/>
      <period>
        <start value="2017-10-13T02:09:08.764Z"/>
        <end value="2017-10-13T02:09:08.764Z"/>
      </period>
      <assigner>
        <display value="Organization aCReB76usKUY+uYkDbhMqg=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse zDhX4StFkPp95NZfQ/iLpA=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
      <display value="Processing Complete"/>
      <userSelected value="false"/>
    </coding>
    <text value="V3qjxOWUGDmuqMu1QgUmeg=="/>
  </outcome>
  <disposition value="VVxGQGNy6tywA8BAXDMZQA=="/>
  <related>
    <claim>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/UZ31VCBQ3i6p77mSyIHCXQ=="/>
        <value value="KK43hNz/RU4jWP/qY3EffA=="/>
      </identifier>
      <display value="Claim TU5bCSKGMPHbjzbd/usZDw=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="true"/>
      </coding>
      <text value="pnjJz4XgR1vD7EzHKSasRg=="/>
    </relationship>
    <reference>
      <use value="temp"/>
      <type>
        <text value="Aw4lWxrN/YAzKxS5rCFp4g=="/>
      </type>
      <system value="http://projectcrucible.org/QOy3g0Xm5kFO+mU39L+AMw=="/>
      <value value="nqM3YomjsRHmQVgSoK5f0A=="/>
      <period>
        <start value="2017-10-13T02:09:08.768Z"/>
        <end value="2017-10-13T02:09:08.768Z"/>
      </period>
      <assigner>
        <display value="Organization IeOkpcJUBOxQRF0Vnpl/Mg=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="rkL6W5X1s73H4My1q6Jo6Q=="/>
      </type>
      <system value="http://projectcrucible.org/UaR1uYAbwFUI7T5nrGOtPA=="/>
      <value value="JlepPbKexcW3QMdeAE60eg=="/>
      <period>
        <start value="2017-10-13T02:09:08.768Z"/>
        <end value="2017-10-13T02:09:08.768Z"/>
      </period>
      <assigner>
        <display value="Organization v8WGc5BjrYw7Seu0UcY5LA=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest L70aGVlUrfi4xLQje8m+dA=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="official"/>
      <type>
        <text value="PSRkk81JJhVbzI771yhxZA=="/>
      </type>
      <system value="http://projectcrucible.org/5X4arHswr+o5jEjlQtYt9A=="/>
      <value value="aDiBn2TL9AccISlpxNiqng=="/>
      <period>
        <start value="2017-10-13T02:09:08.769Z"/>
        <end value="2017-10-13T02:09:08.769Z"/>
      </period>
      <assigner>
        <display value="Organization DNihSX3nBiCf/1XBBbVsCA=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest rqPusRgVR4uLNBFmIivSvQ=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="subscriber"/>
        <display value="Subscriber"/>
        <userSelected value="false"/>
      </coding>
      <text value="mfvKkQUX9MjXVQe5/mz6GA=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="patient"/>
        <display value="Patient"/>
        <userSelected value="false"/>
      </coding>
      <text value="UzPteoTkIk+rUFcqt4zFwg=="/>
    </resourceType>
    <party>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/spL/cKJr1/yQoXPhaKmNwg=="/>
        <value value="8BXnu2oItt9gyfmxOFZAWw=="/>
      </identifier>
      <display value="Practitioner EgJvS5HFmGo3ZwBdgJXpOA=="/>
    </party>
  </payee>
  <information>
    <sequence value="90"/>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/claiminformationcategory"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="false"/>
      </coding>
      <text value="yaQ4s+TyctnH+29YENBq4g=="/>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/claim-exception"/>
        <code value="disabled"/>
        <display value="Disabled"/>
        <userSelected value="false"/>
      </coding>
      <text value="0fyeo5dTJXBFU/DzPlr3Kw=="/>
    </code>
    <timingDate value="2017-10-13"/>
    <valueAttachment>
      <contentType value="application/x-dtbook+xml"/>
      <language value="it-IT"/>
      <url value="http://projectcrucible.org/dfkbRIvWhl60c3vX2OjMlw=="/>
      <size value="82"/>
      <hash value="sbetPAzL6L6tZEidQy1FNA=="/>
      <title value="KBfxg3H0TPqbWxATsOMZ9Q=="/>
      <creation value="2017-10-13T02:09:08.775Z"/>
    </valueAttachment>
    <reason>
      <system value="http://hl7.org/fhir/missingtoothreason"/>
      <code value="o"/>
      <display value="O"/>
      <userSelected value="false"/>
    </reason>
  </information>
  <careTeam>
    <sequence value="41"/>
    <provider>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/9LdaNk/TDvjS4m+yzkZwPw=="/>
        <value value="06vNYiu9tF5+I5twaw/cAA=="/>
      </identifier>
      <display value="Organization Defy0axPKxUGRg+VsuHq0A=="/>
    </provider>
    <responsible value="false"/>
    <role>
      <coding>
        <system value="http://hl7.org/fhir/claimcareteamrole"/>
        <code value="other"/>
        <display value="Other"/>
        <userSelected value="true"/>
      </coding>
      <text value="XoTQJkcyQIS2Du29Xe302Q=="/>
    </role>
    <qualification>
      <coding>
        <system value="http://hl7.org/fhir/ex-providerqualification"/>
        <code value="311405"/>
        <display value="Dentist"/>
        <userSelected value="true"/>
      </coding>
      <text value="c5QRLw3ydiYS/21o8ekGew=="/>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="86"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://projectcrucible.org/YISxeTF3U8Xnma041qHCyA=="/>
        <code value="O9+WG1h8eUpMHG3PkQUnhA=="/>
        <display value="3sGQt82dP4WM2ZVxLCouvw=="/>
        <userSelected value="false"/>
      </coding>
      <text value="UbUV20jjWxPKKIlBocKh/g=="/>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosistype"/>
        <code value="discharge"/>
        <display value="Discharge Diagnosis"/>
        <userSelected value="true"/>
      </coding>
      <text value="UAU8z+30+XCr+qFI1aeu2Q=="/>
    </type>
    <packageCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-diagnosisrelatedgroup"/>
        <code value="100"/>
        <display value="Normal Vaginal Delivery"/>
        <userSelected value="false"/>
      </coding>
      <text value="iFz81P/xiI7qzogLhSrENg=="/>
    </packageCode>
  </diagnosis>
  <procedure>
    <sequence value="48"/>
    <date value="2017-10-13T02:09:08.784Z"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
        <code value="123003"/>
        <display value="PROC-3"/>
        <userSelected value="false"/>
      </coding>
      <text value="Zg6Ri7+dYXVU+te4u9KumQ=="/>
    </procedureCodeableConcept>
  </procedure>
  <precedence value="79"/>
  <insurance>
    <coverage>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/K2uo2YcNqMsKrWBEuK3lxQ=="/>
        <value value="BbttjdUjAZJ0wC+d/YaVOQ=="/>
      </identifier>
      <display value="Coverage o3N3tiQ72mB6V2sYIbbe8A=="/>
    </coverage>
    <preAuthRef value="nnmsqhllxegrXJftA0hnWA=="/>
  </insurance>
  <accident>
    <date value="2017-10-13"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="SPT"/>
        <display value="Sporting Accident"/>
        <userSelected value="true"/>
      </coding>
      <text value="RuU3eCivc3yUs/i79N1Pyw=="/>
    </type>
    <locationReference>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/qHuM5vz6HOUOwP2i8+/x5g=="/>
        <value value="PtF5/XqTP7udhAOm25DMUQ=="/>
      </identifier>
      <display value="Location jA978RIu83y60GraUBAhMw=="/>
    </locationReference>
  </accident>
  <employmentImpacted>
    <start value="2017-10-13T02:09:08.787Z"/>
    <end value="2017-10-13T02:09:08.787Z"/>
  </employmentImpacted>
  <hospitalization>
    <start value="2017-10-13T02:09:08.787Z"/>
    <end value="2017-10-13T02:09:08.787Z"/>
  </hospitalization>
  <item>
    <sequence value="11"/>
    <careTeamLinkId value="27"/>
    <diagnosisLinkId value="88"/>
    <procedureLinkId value="53"/>
    <informationLinkId value="16"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0451"/>
        <display value="Emergency Room - EM/EMTALA"/>
        <userSelected value="false"/>
      </coding>
      <text value="rUkgLhUQPSc/+XFgeG7luA=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="1"/>
        <display value="Medical Care"/>
        <userSelected value="false"/>
      </coding>
      <text value="e3oWa5JGFBxQezSboAaMhA=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1201"/>
        <display value="Exam, recall"/>
        <userSelected value="false"/>
      </coding>
      <text value="WAwFPjW5dcYA14RFqOo3xQ=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="c"/>
        <display value="TMJ treatment"/>
        <userSelected value="false"/>
      </coding>
      <text value="hRMZ/HJwrLUJWPrijYLi+A=="/>
    </modifier>
    <programCode>
      <coding>
        <system value="http://hl7.org/fhir/ex-programcode"/>
        <code value="none"/>
        <display value="None"/>
        <userSelected value="false"/>
      </coding>
      <text value="GF++6Q/h+SL6/rkMNem3WA=="/>
    </programCode>
    <servicedDate value="2017-10-13"/>
    <locationReference>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/NDuK9k5QcQvaug6087t1gA=="/>
        <value value="+wRRj59hu2/GE0eglDx4TA=="/>
      </identifier>
      <display value="Location soCrlS/u7XwHE/7HWuY2pA=="/>
    </locationReference>
    <quantity>
      <value value="0.3951033582545552"/>
      <unit value="qenVYIi3CgfpNTQKB7mpAw=="/>
      <system value="http://projectcrucible.org/NO7l9N3ERvJUlOW5ohNKJw=="/>
      <code value="Kd0vtWlmapA433mI91lrzw=="/>
    </quantity>
    <unitPrice>
      <value value="0.5911367166405781"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <factor value="0.45777633866748024"/>
    <net>
      <value value="0.5254300876462547"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <udi>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/2ILP+fiCkeUzi8vK33Wt9w=="/>
        <value value="oJbaoSCVZ/jnauOzqyopIw=="/>
      </identifier>
      <display value="Device DMUbGrb2N3OPtbiE+UTp1A=="/>
    </udi>
    <bodySite>
      <coding>
        <system value="http://hl7.org/fhir/ex-tooth"/>
        <code value="35"/>
        <display value="35"/>
        <userSelected value="true"/>
      </coding>
      <text value="RNxZGZrPyiFmKIGLLdcbSQ=="/>
    </bodySite>
    <subSite>
      <coding>
        <system value="http://hl7.org/fhir/FDI-surface"/>
        <code value="MOD"/>
        <display value="Mesioclusodistal"/>
        <userSelected value="true"/>
      </coding>
      <text value="KjzVmYsJ7F8HHRhJ/Uze8g=="/>
    </subSite>
    <encounter>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/pVKMZRgXhy5p1FlSOCIt0w=="/>
        <value value="flB8ijqOM/h70nFyfoX8yg=="/>
      </identifier>
      <display value="Encounter 5OA46CgyAWTZeBW4ba4J4w=="/>
    </encounter>
    <noteNumber value="63"/>
    <adjudication>
      <category>
        <text value="kY2BlW142XPrUV3ZLyWm5Q=="/>
      </category>
      <reason>
        <text value="S8wr8KLoZqMO1DamQju8Ww=="/>
      </reason>
      <amount>
        <value value="0.28864077283587264"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.7753074587993493"/>
    </adjudication>
  </item>
  <addItem>
    <sequenceLinkId value="18"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0010"/>
        <display value="Vision Clinic"/>
        <userSelected value="true"/>
      </coding>
      <text value="pNiDmJexnH24YHBKEHJCKw=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="25"/>
        <display value="Restorative"/>
        <userSelected value="false"/>
      </coding>
      <text value="bXV4XrEZLxElVlFGNhRKNA=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="11104"/>
        <display value="Polishing, 4 unit"/>
        <userSelected value="false"/>
      </coding>
      <text value="DvuvnGM8lwRmH+evW+VyMA=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="rooh"/>
        <display value="Rush or Outside of office hours"/>
        <userSelected value="false"/>
      </coding>
      <text value="0iAu4TdjlP5UK9FfuFsTyQ=="/>
    </modifier>
    <fee>
      <value value="0.6734239305333917"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="100"/>
    <adjudication>
      <category>
        <text value="70bdyWNcP7HB9WuvEQVxgQ=="/>
      </category>
      <reason>
        <text value="ZgkdqcQRFrIa8OI+Fwsm7Q=="/>
      </reason>
      <amount>
        <value value="0.15807919177058938"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.25089121982354146"/>
    </adjudication>
  </addItem>
  <totalCost>
    <value value="0.7993169347502822"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.5580606721758306"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.5193972578612122"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="9KNvBZZjillq+5iCTAQ3yQ=="/>
    </type>
    <adjustment>
      <value value="0.460580670361334"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a001"/>
        <display value="Prior Payment Reversal"/>
        <userSelected value="true"/>
      </coding>
      <text value="wtd6lMuShVgDSeRbenRfug=="/>
    </adjustmentReason>
    <date value="2017-10-13"/>
    <amount>
      <value value="0.27837897961995695"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="official"/>
      <type>
        <text value="bTg8zrRJuChqK7HCstudCw=="/>
      </type>
      <system value="http://projectcrucible.org/jKyoGfvfR/z/0SFjUjfRkw=="/>
      <value value="WDMR625rE9A+Ynm97uXksw=="/>
      <period>
        <start value="2017-10-13T02:09:08.808Z"/>
        <end value="2017-10-13T02:09:08.808Z"/>
      </period>
      <assigner>
        <display value="Organization Mn5NuoGTsypft1nIA5iYVg=="/>
      </assigner>
    </identifier>
  </payment>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="1"/>
      <display value="Form #1"/>
      <userSelected value="false"/>
    </coding>
    <text value="aXnK3zBJiqFp3Tztn8NWNg=="/>
  </form>
  <processNote>
    <number value="73"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="printoper"/>
        <display value="Print (Operator)"/>
        <userSelected value="false"/>
      </coding>
      <text value="jclfTntwYc+63BhhI+afVA=="/>
    </type>
    <text value="zAEd+YQQhddiOtisZsBMGw=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="sv"/>
        <display value="Svensk"/>
        <userSelected value="false"/>
      </coding>
      <text value="ABbYpurhSwhEUdBDTGpsMw=="/>
    </language>
  </processNote>
  <benefitBalance>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-category"/>
        <code value="pharmacy"/>
        <display value="Pharmacy Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="GBVfSwr4o20Uq/YG07mcuw=="/>
    </category>
    <subCategory>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="F1"/>
        <display value="Medical Coverage"/>
        <userSelected value="false"/>
      </coding>
      <text value="Md4cZup5i92WxGHsJdKMBA=="/>
    </subCategory>
    <excluded value="false"/>
    <name value="dmVj+gTHgkc0+0mdhteuoA=="/>
    <description value="kw15QwPxXWZLdtG8hjytiw=="/>
    <network>
      <coding>
        <system value="http://hl7.org/fhir/benefit-network"/>
        <code value="out"/>
        <display value="Out of Network"/>
        <userSelected value="false"/>
      </coding>
      <text value="JDRmt/QxU6hZi5Wk4JvwZg=="/>
    </network>
    <unit>
      <coding>
        <system value="http://hl7.org/fhir/benefit-unit"/>
        <code value="family"/>
        <display value="Family"/>
        <userSelected value="true"/>
      </coding>
      <text value="QTZ2mFjqLLo7cvqUjoj/Ow=="/>
    </unit>
    <term>
      <coding>
        <system value="http://hl7.org/fhir/benefit-term"/>
        <code value="annual"/>
        <display value="Annual"/>
        <userSelected value="true"/>
      </coding>
      <text value="RSpXRPuW16K309QZ1Gtr/w=="/>
    </term>
    <financial>
      <type>
        <text value="YNkUp8J6bvbgZgh7dE65OQ=="/>
      </type>
      <allowedMoney>
        <value value="0.15678738645719925"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </allowedMoney>
      <usedMoney>
        <value value="0.4643505991629845"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>

ExplanationOfBenefit "10" Version "1"

Created by ANONYMOUS (Unknown) at 10/13/2017 6:09:09 AM(UTC)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.
Updated: by

7Svqq0eB2L5szJKO69wUuQ==

<?xml version="1.0" encoding="UTF-8"?>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="10"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-10-13T06:09:09Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="ru"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">7Svqq0eB2L5szJKO69wUuQ==</div>
  </text>
  <identifier>
    <use value="official"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/identifier-type"/>
        <code value="SNO"/>
        <display value="Serial Number"/>
        <userSelected value="false"/>
      </coding>
      <text value="HT+LgmAsq918k91VTq+msA=="/>
    </type>
    <system value="http://projectcrucible.org/9ZjasQyZ8oqiqCYCvTVw4Q=="/>
    <value value="MXOPNwU6CSK7rC93lxCTvg=="/>
    <period>
      <start value="2017-10-13T02:09:08.748Z"/>
      <end value="2017-10-13T02:09:08.748Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/XELn/Y2Gvb3EabxFYs7IJg=="/>
        <value value="H6+U8SuKR8zKCYfx6PXR7w=="/>
      </identifier>
      <display value="Organization HHKhoVHVYMBmnfaPL3fH3w=="/>
    </assigner>
  </identifier>
  <status value="entered-in-error"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="oral"/>
      <display value="Oral"/>
      <userSelected value="false"/>
    </coding>
    <text value="ZcF6LocgXO995EyclFNeFg=="/>
  </type>
  <subType>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimsubtype"/>
      <code value="ortho"/>
      <display value="Orthodontic Claim"/>
      <userSelected value="true"/>
    </coding>
    <text value="GhTslkoXGb3dBABwbMaFXQ=="/>
  </subType>
  <patient>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="2RdlnTFj58IFXFgu2PMsnA=="/>
      </type>
      <system value="http://projectcrucible.org/TVo3+bW212ncqgQI9YKLGw=="/>
      <value value="kHlZ/9HLgGea/RhMullO4w=="/>
      <period>
        <start value="2017-10-13T02:09:08.751Z"/>
        <end value="2017-10-13T02:09:08.751Z"/>
      </period>
      <assigner>
        <display value="Organization csZi1sriYpAWPAHbP2F5eQ=="/>
      </assigner>
    </identifier>
    <display value="Patient mj6nVAAj3wZWVLP5vzR08Q=="/>
  </patient>
  <billablePeriod>
    <start value="2017-10-13T02:09:08.751Z"/>
    <end value="2017-10-13T02:09:08.751Z"/>
  </billablePeriod>
  <created value="2017-10-13T02:09:08.751Z"/>
  <enterer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="MI6NDUOCJf+8fG3U+qARog=="/>
      </type>
      <system value="http://projectcrucible.org/3qbINUv2VQ0hOis5A1uqxA=="/>
      <value value="Hz4ZLN5ce0ZjA09AM/yH/Q=="/>
      <period>
        <start value="2017-10-13T02:09:08.752Z"/>
        <end value="2017-10-13T02:09:08.752Z"/>
      </period>
      <assigner>
        <display value="Organization tDV0CyjECbsI3sY2yHYZ0w=="/>
      </assigner>
    </identifier>
    <display value="Practitioner AS8HKVY3pAUpPvX62tg5HQ=="/>
  </enterer>
  <insurer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="RA3TXjKxezQAEJ+MHUzPrQ=="/>
      </type>
      <system value="http://projectcrucible.org/OeIefPx7obCdcG9XQT3tYA=="/>
      <value value="6DJrirmqKS4nMEo12O+3LQ=="/>
      <period>
        <start value="2017-10-13T02:09:08.752Z"/>
        <end value="2017-10-13T02:09:08.752Z"/>
      </period>
      <assigner>
        <display value="Organization 2gwWttLu5vKoqKST/W/2xg=="/>
      </assigner>
    </identifier>
    <display value="Organization ORaUo7TSf65pcV63UbXxrA=="/>
  </insurer>
  <provider>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="s+RTFcNNt3gdKt5EqoXcBQ=="/>
      </type>
      <system value="http://projectcrucible.org/EsPGEVCEfXJypKtdogENfg=="/>
      <value value="evt5arNQ0DnxU5ngtyRJng=="/>
      <period>
        <start value="2017-10-13T02:09:08.756Z"/>
        <end value="2017-10-13T02:09:08.756Z"/>
      </period>
      <assigner>
        <display value="Organization itLHwDeaK1XM6IMbNePTFg=="/>
      </assigner>
    </identifier>
    <display value="Practitioner PEeUwiTo1ImL6w4vN4CGAw=="/>
  </provider>
  <organization>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="osv1/kKgukbd9j/PzsgMcA=="/>
      </type>
      <system value="http://projectcrucible.org/p7CV40XF55j2FmtwLOU1PA=="/>
      <value value="NvCYCnTtGZPRTMJkfoVykw=="/>
      <period>
        <start value="2017-10-13T02:09:08.757Z"/>
        <end value="2017-10-13T02:09:08.757Z"/>
      </period>
      <assigner>
        <display value="Organization GXpHXnvAVaHf8LoNKGx4TQ=="/>
      </assigner>
    </identifier>
    <display value="Organization ytxHJUSw0bNApOUu4mazvQ=="/>
  </organization>
  <referral>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="NVzBVYY7rzSx7Mdhi2wfCA=="/>
      </type>
      <system value="http://projectcrucible.org/VNbbU+AyTv2z7WkzpzTW+Q=="/>
      <value value="ummFsK3Vc9lAFzllQd4MFA=="/>
      <period>
        <start value="2017-10-13T02:09:08.757Z"/>
        <end value="2017-10-13T02:09:08.757Z"/>
      </period>
      <assigner>
        <display value="Organization GBJivVHa91bHP6n+QsBlpg=="/>
      </assigner>
    </identifier>
    <display value="ReferralRequest KLn5H2Oo/40gMKylNjpy6Q=="/>
  </referral>
  <facility>
    <identifier>
      <use value="official"/>
      <type>
        <text value="2th8bnVxsVZ+ONxaUx9XBQ=="/>
      </type>
      <system value="http://projectcrucible.org/6Kcxa99sKj8dp9z3LhK2BA=="/>
      <value value="24LSansJoNIJngynqkdYjw=="/>
      <period>
        <start value="2017-10-13T02:09:08.758Z"/>
        <end value="2017-10-13T02:09:08.758Z"/>
      </period>
      <assigner>
        <display value="Organization LXHluN74wOOUzP2dLvxiIw=="/>
      </assigner>
    </identifier>
    <display value="Location bcYwtsLpPt0qGEjsZ1YZHw=="/>
  </facility>
  <claim>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="7HVP0VH5TyH0a9FWuAbE4g=="/>
      </type>
      <system value="http://projectcrucible.org/7RjeyCztEuCbS4vfVmb+vw=="/>
      <value value="/Qk4drKjZEPJlRB7g9hF0A=="/>
      <period>
        <start value="2017-10-13T02:09:08.758Z"/>
        <end value="2017-10-13T02:09:08.758Z"/>
      </period>
      <assigner>
        <display value="Organization 2G1tuW0uFmubmbe9Ynt89A=="/>
      </assigner>
    </identifier>
    <display value="Claim dU6PxoIXM+LS9Au+rRBiyg=="/>
  </claim>
  <claimResponse>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="rRrV7n8mqopZcSL7++iVkg=="/>
      </type>
      <system value="http://projectcrucible.org/Du+WqchJDEA/WLN+omYHlA=="/>
      <value value="oNuOU9RCuVUFVNVuGnnrFA=="/>
      <period>
        <start value="2017-10-13T02:09:08.764Z"/>
        <end value="2017-10-13T02:09:08.764Z"/>
      </period>
      <assigner>
        <display value="Organization aCReB76usKUY+uYkDbhMqg=="/>
      </assigner>
    </identifier>
    <display value="ClaimResponse zDhX4StFkPp95NZfQ/iLpA=="/>
  </claimResponse>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
      <display value="Processing Complete"/>
      <userSelected value="false"/>
    </coding>
    <text value="V3qjxOWUGDmuqMu1QgUmeg=="/>
  </outcome>
  <disposition value="jKXwaoc9PaOu1BkEGm932w=="/>
  <related>
    <claim>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/UZ31VCBQ3i6p77mSyIHCXQ=="/>
        <value value="KK43hNz/RU4jWP/qY3EffA=="/>
      </identifier>
      <display value="Claim TU5bCSKGMPHbjzbd/usZDw=="/>
    </claim>
    <relationship>
      <coding>
        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
        <code value="associated"/>
        <display value="Associated Claim"/>
        <userSelected value="true"/>
      </coding>
      <text value="pnjJz4XgR1vD7EzHKSasRg=="/>
    </relationship>
    <reference>
      <use value="temp"/>
      <type>
        <text value="Aw4lWxrN/YAzKxS5rCFp4g=="/>
      </type>
      <system value="http://projectcrucible.org/QOy3g0Xm5kFO+mU39L+AMw=="/>
      <value value="nqM3YomjsRHmQVgSoK5f0A=="/>
      <period>
        <start value="2017-10-13T02:09:08.768Z"/>
        <end value="2017-10-13T02:09:08.768Z"/>
      </period>
      <assigner>
        <display value="Organization IeOkpcJUBOxQRF0Vnpl/Mg=="/>
      </assigner>
    </reference>
  </related>
  <prescription>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="rkL6W5X1s73H4My1q6Jo6Q=="/>
      </type>
      <system value="http://projectcrucible.org/UaR1uYAbwFUI7T5nrGOtPA=="/>
      <value value="JlepPbKexcW3QMdeAE60eg=="/>
      <period>
        <start value="2017-10-13T02:09:08.768Z"/>
        <end value="2017-10-13T02:09:08.768Z"/>
      </period>
      <assigner>
        <display value="Organization v8WGc5BjrYw7Seu0UcY5LA=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest L70aGVlUrfi4xLQje8m+dA=="/>
  </prescription>
  <originalPrescription>
    <identifier>
      <use value="official"/>
      <type>
        <text value="PSRkk81JJhVbzI771yhxZA=="/>
      </type>
      <system value="http://projectcrucible.org/5X4arHswr+o5jEjlQtYt9A=="/>
      <value value="aDiBn2TL9AccISlpxNiqng=="/>
      <period>
        <start value="2017-10-13T02:09:08.769Z"/>
        <end value="2017-10-13T02:09:08.769Z"/>
      </period>
      <assigner>
        <display value="Organization DNihSX3nBiCf/1XBBbVsCA=="/>
      </assigner>
    </identifier>
    <display value="MedicationRequest rqPusRgVR4uLNBFmIivSvQ=="/>
  </originalPrescription>
  <payee>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/payeetype"/>
        <code value="subscriber"/>
        <display value="Subscriber"/>
        <userSelected value="false"/>
      </coding>
      <text value="mfvKkQUX9MjXVQe5/mz6GA=="/>
    </type>
    <resourceType>
      <coding>
        <system value="http://hl7.org/fhir/resource-type-link"/>
        <code value="patient"/>
        <display value="Patient"/>
        <userSelected value="false"/>
      </coding>
      <text value="UzPteoTkIk+rUFcqt4zFwg=="/>
    </resourceType>
    <party