diff --git a/static/openapi.yaml b/static/openapi.yaml index 917a076ce..307fc44bc 100755 --- a/static/openapi.yaml +++ b/static/openapi.yaml @@ -294,6 +294,122 @@ paths: description: "Error: Bad Gateway, e.g. An error occurred contacting the FHIR server." tags: - v3 + /v3/fhir/ExplanationOfBenefit/{resource_id}: + get: + operationId: listReadViewExplanationOfBenefits_v3 + description: "Returns ExplanationOfBenefit FHIR resource identified by resource_id" + summary: "ExplanationOfBenefit FHIR resource identified by resource_id" + parameters: + - name: resource_id + in: path + required: true + description: "ExplanationOfBenefit FHIR resource id, e.g. -9631024438695" + schema: + type: string + responses: + '200': + content: + application/fhir+json: + schema: + $ref: '#/components/schemas/FHIR-JSON-RESOURCE' + examples: + V3FhirExplanationOfBenefitByIdExample: + $ref: '#/components/examples/V3FhirExplanationOfBenefitByIdExample' + description: "ExplanationOfBenefit FHIR resource" + '401': + description: "Error: Unauthorized, e.g. Authentication credentials were not provided." + '404': + description: "Error: Not Found, e.g. The requested resource does not exist." + '502': + description: "Error: Bad Gateway, e.g. An error occurred contacting the FHIR server." + tags: + - v3 + /v3/fhir/ExplanationOfBenefit/: + get: + operationId: listSearchViewExplanationOfBenefits_v3 + description: "Returns ExplanationOfBenefit FHIR resources matching search criteria as a FHIR Bundle" + summary: "ExplanationOfBenefit FHIR resources matching search criteria as a FHIR Bundle" + parameters: + - in: query + name: patient + schema: + type: string + required: false + description: "The patient identifier to search for" + - in: query + name: _lastUpdated + schema: + type: string + required: false + description: |- + Only satisfy the Search if the Beneficiary's _last_updated_ Date falls within a specified _DateRange_. + + A _DateRange_ can be defined by providing _lt_ (less than), _le_ + (less than or equal to), _gt_ (greater than), and/or _ge_ (greater + than or equal to) values. + + This parameter can be included in a request one or more times. + + Inexact timestamps are accepted, but not recommended, since the input will implicitly + be converted to use the server's timezone. + + Examples: + - __lastUpdated=gt2023-01-02T00:00+00:00&\_lastUpdated=lt2023-05-01T00:00+00:00_ defines a range between two provided dates + - __lastUpdated=gt2023-01-02T00:00+00:00_ defines a range between the provided date and today + - __lastUpdated=lt2023-05-01T00:00+00:00_ defines a range from the earliest available records until the provided date + - in: query + name: service-date + schema: + type: string + required: false + description: |- + Only satisfy the Search request if a claim's _billable period_ + falls within a specified _DateRange_. + + A _DateRange_ can be defined by providing _lt_ (less than), _le_ + (less than or equal to), _gt_ (greater than), and/or _ge_ (greater + than or equal to) values. + + This parameter can be included in a request one or more times. + + Inexact timestamps are accepted, but not recommended, since the input will implicitly + be converted to use the server's timezone. + + + Examples: + - _service-date=gt2023-01-02T00:00+00:00&service-date=lt2023-05-01T00:00+00:00_ defines a range between two provided dates + - _service-date=gt2023-01-02T00:00+00:00_ defines a range between the provided date and today + - _service-date=lt2023-05-01T00:00+00:00_ defines a range from the earliest available records until the provided date + - in: query + name: startIndex + schema: + type: string + required: false + description: "The offset used for result pagination" + - in: query + name: type + schema: + type: string + required: false + description: "A list of claim types to include" + responses: + '200': + content: + application/fhir+json: + schema: + $ref: '#/components/schemas/FHIR-JSON-RESOURCE' + examples: + V3FhirExplanationOfBenefitExample: + $ref: '#/components/examples/V3FhirExplanationOfBenefitExample' + description: "ExplanationOfBenefit FHIR resources bundle" + '400': + description: "Error: Bad Request, e.g. the _lastUpdated operator is not valid." + '401': + description: "Error: Unauthorized, e.g. Authentication credentials were not provided." + '502': + description: "Error: Bad Gateway, e.g. An error occurred contacting the FHIR server." + tags: + - v3 ########## V2 Endpoints ########## /v2/connect/.well-known/openid-configuration: @@ -34083,368 +34199,10769 @@ components: value: 1275.33 currency: USD - V1FhirExplanationOfBenefitByIdExample: + V3FhirExplanationOfBenefitExample: value: - resourceType: ExplanationOfBenefit - id: outpatient--10000930038021 + resourceType: Bundle + id: 1b5cc2f4-de96-4f75-a68d-375ddab278ba meta: - lastUpdated: '2023-06-14T12:32:51.430-04:00' - extension: - - url: https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt - valueMoney: - value: 4 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt - valueMoney: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt - valueMoney: - value: 10 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt - valueMoney: - value: 60.7 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt - valueMoney: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am - valueMoney: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd - valueCoding: - system: https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd - - url: https://bluebutton.cms.gov/resources/variables/prpayamt - valueMoney: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - url: https://bluebutton.cms.gov/resources/variables/fi_doc_clm_cntl_num - valueIdentifier: - system: https://bluebutton.cms.gov/resources/variables/fi_doc_clm_cntl_num - value: '-426561283' - identifier: - - system: https://bluebutton.cms.gov/resources/variables/clm_id - value: '-10000930038021' - - system: https://bluebutton.cms.gov/resources/identifier/claim-group - value: '-1632178419' - status: active - type: - coding: - - system: https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd - code: '40' - display: Hospital Outpatient claim - - system: https://bluebutton.cms.gov/resources/codesystem/eob-type - code: OUTPATIENT - - system: http://hl7.org/fhir/ex-claimtype - code: professional - display: Professional - - system: https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd - code: W - display: Part B institutional claim record (outpatient [HOP], HHA) - - system: https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd - code: '3' - patient: - reference: Patient/-10000010254647 - billablePeriod: - extension: - - url: https://bluebutton.cms.gov/resources/variables/claim_query_cd - valueCoding: - system: https://bluebutton.cms.gov/resources/variables/claim_query_cd - code: '3' - display: Final bill - start: '2016-09-13' - end: '2016-09-13' - provider: - identifier: - system: https://bluebutton.cms.gov/resources/variables/prvdr_num - value: '014018' - organization: - identifier: - system: http://hl7.org/fhir/sid/us-npi - value: '1225301823' - display: BEHAVIORAL HEALTHCARE CENTER AT HUNTSVILLE - facility: - extension: - - url: https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd - valueCoding: - system: https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd - code: '1' - display: Hospital - identifier: - system: http://hl7.org/fhir/sid/us-npi - value: '1225301823' - display: BEHAVIORAL HEALTHCARE CENTER AT HUNTSVILLE - information: - - sequence: 1 - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/information - code: https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt - display: NCH Weekly Claim Processing Date - timingDate: '2016-09-16' - - sequence: 2 - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/information - code: https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw - display: Claim MCO Paid Switch - code: - coding: - - system: https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw - code: '0' - display: No managed care organization (MCO) payment - - sequence: 3 - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/information - code: https://bluebutton.cms.gov/resources/variables/clm_freq_cd - display: Claim Frequency Code - code: - coding: - - system: https://bluebutton.cms.gov/resources/variables/clm_freq_cd - code: '1' - display: Admit thru discharge claim - - sequence: 4 - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/information - code: https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd - display: Patient Discharge Status Code - code: - coding: - - system: https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd - code: '1' - - sequence: 5 - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/information - code: https://bluebutton.cms.gov/resources/variables/nch_prmry_pyr_cd - display: NCH Primary Payer Code (if not Medicare) - code: - coding: - - system: https://bluebutton.cms.gov/resources/variables/nch_prmry_pyr_cd - careTeam: - - sequence: 2 - provider: - identifier: - system: http://hl7.org/fhir/sid/us-npi - value: '9999987891' - role: - coding: - - system: http://hl7.org/fhir/claimcareteamrole - code: assist - display: Assisting Provider - - sequence: 3 - provider: - identifier: - system: http://hl7.org/fhir/sid/us-npi - value: '9999987891' - role: - coding: - - system: http://hl7.org/fhir/claimcareteamrole - code: primary - display: Primary provider - diagnosis: - - sequence: 1 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: J329 - display: '"CHRONIC SINUSITIS, UNSPECIFIED"' - type: - - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type - code: principal - display: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. - - sequence: 2 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: B9789 - display: OTH VIRAL AGENTS AS THE CAUSE OF DISEASES CLASSD ELSWHR - type: - - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type - code: principal - display: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. - - sequence: 3 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: Z608 - display: OTHER PROBLEMS RELATED TO SOCIAL ENVIRONMENT - - sequence: 4 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: M5450 - - sequence: 5 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: M797 - display: FIBROMYALGIA - - sequence: 6 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: Z733 - display: '"STRESS, NOT ELSEWHERE CLASSIFIED"' - - sequence: 7 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: Z560 - display: '"UNEMPLOYMENT, UNSPECIFIED"' - - sequence: 8 - diagnosisCodeableConcept: - coding: - - system: http://hl7.org/fhir/sid/icd-10 - code: Y93 - display: ACTIVITY CODES - type: - - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type - code: external-first - display: The code used to identify the 1st external cause of injury, poisoning, or other adverse effect. - - sequence: 9 - diagnosisCodeableConcept: - coding: - - system: 'http://hl7.org/fhir/sid/unknown-icd-version/ ' - type: - - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type - code: external - display: A code used to identify an external cause of injury, poisoning, or other adverse effect. - insurance: - coverage: - reference: Coverage/part-b--10000010254647 - item: - - sequence: 1 - careTeamLinkId: - - 3 - revenue: + lastUpdated: '2025-12-04T19:14:36.126+00:00' + type: searchset + total: 10 + link: + - relation: self + url: >- + http://sandbox.fhirv3.bfd.cmscloud.local/v3/fhir/ExplanationOfBenefit/?_count=10&_format=application%2Fjson%2Bfhir&patient=-206068516 + entry: + - resource: + resourceType: ExplanationOfBenefit + id: '-9923875310680' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1447692959' + - resourceType: Practitioner + id: careteam-provider-2 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1972944437' + - resourceType: Practitioner + id: careteam-provider-3 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1720749690' + - resourceType: Practitioner + id: careteam-provider-4 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1972944437' + - resourceType: Practitioner + id: careteam-provider-5 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1003488552' extension: - - url: https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD valueCoding: - system: https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd - code: '4' - coding: - - system: https://bluebutton.cms.gov/resources/variables/rev_cntr - code: '0001' - display: Total charge - service: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/hcpcs - code: '99241' - servicedDate: '2016-09-13' - locationAddress: - state: '01' - quantity: - value: 1 - adjudication: - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt - display: Revenue Center Blood Deductible Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt - display: Revenue Center Cash Deductible Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c - display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt - display: Revenue Center Reduced Coinsurance Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt - display: Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt - display: Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt - display: Revenue Center (Medicare) Provider Payment Amount - amount: - value: 60.7 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt - display: Revenue Center Payment Amount to Beneficiary - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt - display: Revenue Center Patient Responsibility Payment Amount - amount: - value: 0 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: - - system: https://bluebutton.cms.gov/resources/codesystem/adjudication - code: https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt - display: Revenue Center (Medicare) Payment Amount - amount: - value: 60.7 - system: urn:iso:std:iso:4217 - code: USD - - category: - coding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + code: '5' + display: BOTH HOSPITAL AND BENEFICIARY + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM + valueString: '6513' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2025-04-20' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '01312' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FI-ACTN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD' + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + code: '19' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: 'N' + display: Non-assigned claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-9923875310680' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 28760273736343XBY + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '40' + display: MEDICARE OUTPATIENT CLAIM + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: institutional + subType: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType + code: outpatient + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + code: C + start: '2025-04-07' + end: '2025-04-20' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: attending + display: Attending + - sequence: 2 + provider: + reference: '#careteam-provider-2' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: operating + display: Operating + - sequence: 3 + provider: + reference: '#careteam-provider-3' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: otheroperating + display: Other Operating + - sequence: 4 + provider: + reference: '#careteam-provider-4' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: rendering + display: Rendering provider + - sequence: 5 + provider: + reference: '#careteam-provider-5' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: referring + display: Referring provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 20 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD + code: E + - sequence: 3 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: '0455' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD + code: '4' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '45' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: '455' + - sequence: 4 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: W + display: 'Part B institutional claim record (outpatient [HOP], HHA)' + - sequence: 5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: clmrecvddate + timingDate: '2025-04-20' + - sequence: 6 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2025-04-20' + - sequence: 7 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: pointoforigin + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PointOfOrigin' + code: 'N' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD' + code: 'N' + display: RESERVED FOR NATIONAL ASSIGNMENT (NON-NEWBORN) + - sequence: 8 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: discharge-status + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PatDischargeStatus' + code: '32' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD' + code: '32' + display: RESERVED FOR NATIONAL ASSIGNMENT + - sequence: 9 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admtype + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' + code: '9' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD' + code: '9' + - sequence: 10 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_MDCR_INSTNL_MCO_PD_SW + display: MCO Paid Switch + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW + code: '0' + display: No managed care organization (MCO) payment + - sequence: 11 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: drg + code: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software + code: '1' + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.2 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y92.311 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + procedure: + - sequence: 1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: principal + date: '2025-04-11' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: B2111ZZ + - sequence: 2 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: other + date: '2025-04-14' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: 5A1955Z + insurance: + - focal: true + coverage: + display: Part A + item: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '14' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: K + sequence: 1 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '2101' + display: ALTERNATIVE THERAPY SERVICES - ACUPUNCTURE + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '2101' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '0' + display: Charges are subject to deductible and coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + servicedDate: '2025-04-07' + quantity: + value: 3.39 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1053.73 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.09 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1073.96 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.98 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 3.29 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.37 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.96 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1060.02 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 749.81 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 11.88 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.94 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 11.73 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: U + sequence: 2 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0839 + display: >- + PERITONEAL DIALYSIS - OUTPATIENT OR HOME - OTHER OUTPATIENT + PERITONEAL DIALYSIS + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0839 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '4' + display: >- + No charge or units associated with this revenue center code. + (For multiple HCPCS per single revenue center code) For + revenue center code 0001, the following MSP override values + may be present: + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + servicedDate: '2025-04-07' + quantity: + value: 3.72 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 776.32 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.44 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 431.98 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.28 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.95 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.06 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.23 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 654.34 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 567.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 12.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.41 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 11.76 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: 'Y' + sequence: 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0146' + display: ROOM & BOARD - DELUXE PRIVATE - DETOXIFICATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0146' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '3' + display: Charges are not subject to deductible or coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2025-04-07' + quantity: + value: 2.2 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 112.69 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.1 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 445.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0.2 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.09 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.01 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.83 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 528.93 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 926.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 3.51 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.77 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 7.27 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 535.45 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: U + sequence: 4 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0241' + display: ALL INCLUSIVE ANCILLARY - BASIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0241' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: M + display: >- + Override code; EGHP (employer group health plan) services + involved + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2025-04-07' + quantity: + value: 0.62 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 99.81 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.82 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 304.33 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0.58 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.69 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.15 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.07 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 807.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1152.5 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 9.38 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.61 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 13.73 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: M + sequence: 5 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0312' + display: LABORATORY PATHOLOGY - HISTOLOGY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0312' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '2' + display: Charges are not subject to coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + servicedDate: '2025-04-07' + quantity: + value: 2 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 73.89 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 4.5 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 988.59 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.8 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.03 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.52 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.19 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 767.78 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 867.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 12.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.44 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 12.81 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 861.86 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q3 + sequence: 6 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0663' + display: RESPITE CARE - DAILY RESPITE CHARGE + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0663' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2025-04-07' + quantity: + value: 0.72 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 423.72 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1377.52 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.21 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.16 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.99 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.86 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1022.68 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 312.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 5.2 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.54 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 6.75 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q4 + sequence: 7 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0207' + display: INTENSIVE CARE UNIT - BURN CARE + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0207' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: 'N' + display: Override code; non-EGHP services involved + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2025-04-07' + quantity: + value: 4.58 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 488.63 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.98 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 526.95 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.04 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.39 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.09 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.98 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 607.4 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 566.42 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 10.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.73 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 2.83 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: W + sequence: 8 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0988 + display: PROFESSIONAL FEES (EXTENSION OF 096X AND 097X) - CONSULTATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0988 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: M + display: >- + Override code; EGHP (employer group health plan) services + involved + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '32' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + servicedDate: '2025-04-07' + quantity: + value: 3.35 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 858.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.07 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 525.17 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 4.53 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.32 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.55 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.15 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 157.23 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1412.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 1.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.47 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 11.25 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180031 + quantity: + value: 518.07 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '6' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: 'Y' + sequence: 9 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0139 + display: ROOM & BOARD - SEMI-PRIVATE - THREE AND FOUR BEDS - OTHER + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0139 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2025-04-07' + quantity: + value: 3.1 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 695.84 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.76 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1055.88 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.04 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.82 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.61 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.94 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 7.25 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1080.43 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 6.53 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.06 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 12.8 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q3 + sequence: 10 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0379 + display: ANESTHESIA - OTHER ANESTHESIA + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0379 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '3' + display: Charges are not subject to deductible or coinsurance + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2025-04-07' + quantity: + value: 2.66 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 270.77 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.48 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 270.77 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.68 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.75 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1298.8 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 833.2 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 3.33 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.83 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.28 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180031 + quantity: + value: 798.82 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: B + sequence: 11 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0304' + display: LABORATORY - NON-ROUTINE DIALYSIS + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0304' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + servicedDate: '2025-04-07' + quantity: + value: 0.7 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 541.21 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.22 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1315.3 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0.11 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.53 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.39 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.77 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 112.54 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 838.69 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 2.77 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.84 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 8.75 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338011704 + quantity: + value: 659.75 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '9' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: 'Y' + sequence: 12 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0280 + display: ONCOLOGY - GENERAL CLASSIFICATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0280 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + servicedDate: '2025-04-07' + quantity: + value: 2.92 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1370.28 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.7 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 267.69 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.08 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.39 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.39 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.37 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1022.77 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 403.9 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 5.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.65 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 11.92 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 832.42 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + adjudication: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-IP-PPS-DRG-WT-NUM + valueDecimal: 1.5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator + code: benefitpaymentstatus + display: Benefit Payment Status + reason: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus + code: other + display: Other + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 874922.5625 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 5.96 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 162.97 + currency: USD + payment: + amount: + value: 166802.53 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1003.79 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_COINSRNC_AMT + display: Beneficiary Part A Coinsurance Liability Amount + usedMoney: + value: 0.34 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_BLOOD_LBLTY_AMT + display: Beneficiary Blood Deductible Liability Amount + usedMoney: + value: 5.05 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_NCVRD_CHRG_AMT + display: Inpatient(or other Part A) Non-covered Charge Amount + usedMoney: + value: 708120.06 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_LRD_USE_CNT + display: >- + Beneficiary Medicare Lifetime Reserve Days (LRD) Used + Count + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HHA_TOT_VISIT_CNT + display: Claim HHA Total Visit Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HOSPC_PRD_CNT + display: Beneficiary's Hospice Period Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_MDCR_COINS_DAY_CNT + display: Beneficiary Total Coinsurance Days Count + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_CVRD_DAY_CNT + display: Claim Medicare Utilization Day Count + usedUnsignedInt: 8 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PER_DIEM_AMT + display: Claim Pass Thru Per Diem Amount + usedMoney: + value: 300.31 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_BENE_PD_AMT + display: >- + The amount paid, from the Medicare trust fund, to the + beneficiary for the services reported on the claim. + usedMoney: + value: 3.8 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_DSPRPRTNT_AMT + display: Claim PPS Capital Disproportionate Share Amount + usedMoney: + value: 2815.44 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_EXCPTN_AMT + display: Claim PPS Capital Exception Amount + usedMoney: + value: 2.9 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_FSP_AMT + display: Claim PPS Capital Federal Specific Portion (FSP) Amount + usedMoney: + value: 13.61 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_IME_AMT + display: Claim PPS Capital Indirect Medical Education (IME) Amount + usedMoney: + value: 12.06 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_OUTLIER_AMT + display: Claim PPS Capital Outlier Amount + usedMoney: + value: 10.47 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT + display: Claim PPS Old Capital Hold Harmless Amount + usedMoney: + value: 1.94 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_TOT_AMT + display: Claim Total PPS Capital Amount + usedMoney: + value: 16.51 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_PRMRY_PYR_AMT + display: Primary Payer (if not Medicare) Claim Paid Amount + usedMoney: + value: 368.94 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PRFNL_AMT + display: Professional Component Charge Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_DRG_OUTLIER_AMT + display: DRG Outlier Approved Payment Amount + usedMoney: + value: 2727.35 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_BENE_DDCTBL_AMT + display: Beneficiary Inpatient (or other Part A) Deductible Amount + usedMoney: + value: 2.82 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_HIPPS_UNCOMPD_CARE_AMT + display: Claim Uncompensated Care Payment Amount + usedMoney: + value: 135.22 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_DSPRTNT_AMT + display: Operating Disproportionate Share Amount + usedMoney: + value: 932.23 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_IME_AMT + display: Operating Indirect Medical Education Amount + usedMoney: + value: 10670.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1003.79 + currency: USD + - resource: + resourceType: ExplanationOfBenefit + id: '-9631024438695' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1558719914' + - resourceType: Practitioner + id: careteam-provider-2 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1447692959' + - resourceType: Practitioner + id: careteam-provider-3 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1942945159' + - resourceType: Practitioner + id: careteam-provider-4 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1437702123' + extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + code: 'N' + display: MEDICAL NECESSITY + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM + valueString: '6056' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2018-11-03' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '14312' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-DISP-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD' + code: '58' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FI-ACTN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD' + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + code: T + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: L + display: Assigned Claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-9631024438695' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 24550267688014LFN + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '10' + display: MEDICARE HHA CLAIM + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: institutional + subType: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType + code: inpatient + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + code: '1' + start: '2018-10-27' + end: '2018-11-03' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: attending + display: Attending + - sequence: 2 + provider: + reference: '#careteam-provider-2' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: operating + display: Operating + - sequence: 3 + provider: + reference: '#careteam-provider-3' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: otheroperating + display: Other Operating + - sequence: 4 + provider: + reference: '#careteam-provider-4' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: rendering + display: Rendering provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 0 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD + code: D + - sequence: 3 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: '0137' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD + code: '1' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '13' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: '137' + - sequence: 4 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: U + display: >- + Both Part A and B institutional home health agency (HHA) claim + records + - sequence: 5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admissionperiod + timingPeriod: + start: '2018-10-27' + end: '2018-11-03' + - sequence: 6 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: clmrecvddate + timingDate: '2018-11-03' + - sequence: 7 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2018-11-03' + - sequence: 8 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: pointoforigin + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PointOfOrigin' + code: S + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD' + code: S + display: RESERVED FOR NATIONAL ASSIGNMENT (NON-NEWBORN) + - sequence: 9 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: discharge-status + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PatDischargeStatus' + code: '37' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD' + code: '37' + display: RESERVED FOR NATIONAL ASSIGNMENT + - sequence: 10 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admtype + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' + code: '4' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD' + code: '4' + - sequence: 11 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_MDCR_INSTNL_MCO_PD_SW + display: MCO Paid Switch + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW + code: '1' + display: MCO paid provider for the claim + - sequence: 12 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: drg + code: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software + code: '11' + - sequence: 13 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_HHA_RFRL_CD + display: Claim Referral Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM_HHA_RFRL_CD' + code: '7' + display: >- + EMERGENCY ROOM - THE PATIENT WAS ADMITTED UPON THE + RECOMMENDATION OF THIS FACILITY'S EMERGENCY ROOM PHYSICIAN. + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E11.69 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.5 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: admitting + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: '0' + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E11.69 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + insurance: + - focal: true + coverage: + display: Part A + item: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '16' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: E + sequence: 1 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0963 + display: >- + PROFESSIONAL FEES (ALSO SEE 097X AND 098X) - ANESTHESIOLOGIST + (MD) + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0963 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '2' + display: Charges are not subject to coinsurance + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2018-10-27' + quantity: + value: 2.9 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 572.55 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.72 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1190.09 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.11 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.07 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.25 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 226.47 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 534.34 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 12.6 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.29 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 6.12 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264780020 + quantity: + value: 474.2 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '13' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: U + sequence: 2 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0641' + display: 'HOME IV THERAPY SERVICES - NON-ROUTINE NURSING, CENTRAL LINE' + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0641' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: 'N' + display: Override code; non-EGHP services involved + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2018-10-27' + quantity: + value: 2.41 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 242.23 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.4 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 415.56 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.94 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.78 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.18 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 340.47 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 491.71 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 2.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.01 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 1.57 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 831.67 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: H + sequence: 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0695 + display: >- + PRE-HOSPICE/PALLIATIVE CARE SERVICES - INPATIENT CARE + (EFFECTIVE 1/1/14) + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0695 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: US + servicedDate: '2018-10-27' + quantity: + value: 2.41 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 508.27 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.29 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1273.41 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.7 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.97 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.29 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1341.09 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 726.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 8.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.21 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.26 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: M + sequence: 4 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0133' + display: ROOM & BOARD - SEMI-PRIVATE - THREE AND FOUR BEDS - PEDIATRIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0133' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2018-10-27' + quantity: + value: 4.21 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1453.68 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.53 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 395.11 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.4 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.72 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.38 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.34 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1042.1 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1486.08 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 14.26 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.03 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.71 + currency: USD + adjudication: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-IP-PPS-DRG-WT-NUM + valueDecimal: 0.67 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator + code: benefitpaymentstatus + display: Benefit Payment Status + reason: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus + code: other + display: Other + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 99816.1171875 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 968.73 + currency: USD + payment: + amount: + value: 17103.19 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1382.05 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_COINSRNC_AMT + display: Beneficiary Part A Coinsurance Liability Amount + usedMoney: + value: 24.88 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_BLOOD_LBLTY_AMT + display: Beneficiary Blood Deductible Liability Amount + usedMoney: + value: 20.8 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_NCVRD_CHRG_AMT + display: Inpatient(or other Part A) Non-covered Charge Amount + usedMoney: + value: 82712.93 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_LRD_USE_CNT + display: >- + Beneficiary Medicare Lifetime Reserve Days (LRD) Used + Count + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HHA_TOT_VISIT_CNT + display: Claim HHA Total Visit Count. + usedUnsignedInt: 18 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HOSPC_PRD_CNT + display: Beneficiary's Hospice Period Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_MDCR_COINS_DAY_CNT + display: Beneficiary Total Coinsurance Days Count + usedUnsignedInt: 1 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_CVRD_DAY_CNT + display: Claim Medicare Utilization Day Count + usedUnsignedInt: 1 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PER_DIEM_AMT + display: Claim Pass Thru Per Diem Amount + usedMoney: + value: 119.41 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_BENE_PD_AMT + display: >- + The amount paid, from the Medicare trust fund, to the + beneficiary for the services reported on the claim. + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_DSPRPRTNT_AMT + display: Claim PPS Capital Disproportionate Share Amount + usedMoney: + value: 3187.83 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_EXCPTN_AMT + display: Claim PPS Capital Exception Amount + usedMoney: + value: 7.74 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_FSP_AMT + display: Claim PPS Capital Federal Specific Portion (FSP) Amount + usedMoney: + value: 11.79 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_IME_AMT + display: Claim PPS Capital Indirect Medical Education (IME) Amount + usedMoney: + value: 4.58 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_OUTLIER_AMT + display: Claim PPS Capital Outlier Amount + usedMoney: + value: 10.62 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT + display: Claim PPS Old Capital Hold Harmless Amount + usedMoney: + value: 10.54 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_TOT_AMT + display: Claim Total PPS Capital Amount + usedMoney: + value: 11.93 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_PRMRY_PYR_AMT + display: Primary Payer (if not Medicare) Claim Paid Amount + usedMoney: + value: 2130.46 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PRFNL_AMT + display: Professional Component Charge Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_DRG_OUTLIER_AMT + display: DRG Outlier Approved Payment Amount + usedMoney: + value: 1105.4 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_BENE_DDCTBL_AMT + display: Beneficiary Inpatient (or other Part A) Deductible Amount + usedMoney: + value: 21.44 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_HIPPS_UNCOMPD_CARE_AMT + display: Claim Uncompensated Care Payment Amount + usedMoney: + value: 25.85 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_DSPRTNT_AMT + display: Operating Disproportionate Share Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_IME_AMT + display: Operating Indirect Medical Education Amount + usedMoney: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1382.05 + currency: USD + - resource: + resourceType: ExplanationOfBenefit + id: '-7294507117384' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1023051596' + - resourceType: Practitioner + id: careteam-provider-2 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1972944437' + - resourceType: Practitioner + id: careteam-provider-3 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1720749690' + - resourceType: Practitioner + id: careteam-provider-4 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1558719914' + extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + code: Q + display: EMPLOYER VOLUNTARY REPORTING + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM + valueString: '5658' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2020-08-25' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '12101' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-DISP-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD' + code: '1' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FI-ACTN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD' + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD + code: B + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: L + display: Assigned Claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-7294507117384' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 55056275030928YBJ + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '50' + display: MEDICARE HOSPICE CLAIM + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: institutional + subType: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType + code: inpatient + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + code: '3' + start: '2020-08-04' + end: '2020-08-25' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: attending + display: Attending + - sequence: 2 + provider: + reference: '#careteam-provider-2' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: operating + display: Operating + - sequence: 3 + provider: + reference: '#careteam-provider-3' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: otheroperating + display: Other Operating + - sequence: 4 + provider: + reference: '#careteam-provider-4' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: rendering + display: Rendering provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 0 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD + code: X + - sequence: 3 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: 079P + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD + code: '7' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '79' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: 79P + - sequence: 4 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: V + display: >- + Part A institutional claim record (inpatient [IP], skilled + nursing facility [SNF], hospice [HOS], or home health agency + [HHA]). + - sequence: 5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admissionperiod + timingPeriod: + start: '2020-08-04' + end: '2020-08-25' + - sequence: 6 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: clmrecvddate + timingDate: '2020-08-25' + - sequence: 7 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2020-08-25' + - sequence: 8 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCVRD_FROM_DT + display: Noncovered Stay From Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2020-08-25' + - sequence: 9 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCVRD_THRU_DT + display: Noncovered Stay Through Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2020-08-25' + - sequence: 10 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_MDCR_EXHSTD_DT + display: Medicare Benefits Exhausted Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2020-08-25' + - sequence: 11 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: pointoforigin + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PointOfOrigin' + code: J + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD' + code: J + display: RESERVED FOR NATIONAL ASSIGNMENT (NON-NEWBORN) + - sequence: 12 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: discharge-status + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PatDischargeStatus' + code: '14' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD' + code: '14' + display: RESERVED FOR NATIONAL ASSIGNMENT + - sequence: 13 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admtype + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' + code: '7' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD' + code: '7' + - sequence: 14 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_MDCR_INSTNL_MCO_PD_SW + display: MCO Paid Switch + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW + code: '0' + display: No managed care organization (MCO) payment + - sequence: 15 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: drg + code: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software + code: '39' + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W30.3XXA + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.2 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: admitting + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.33 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E11.69 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 7 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: '1' + - sequence: 8 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 9 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W61.62 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 10 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: 'Y' + - sequence: 11 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E01.70 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 12 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E02.90 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 13 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W30.3XXA + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + - sequence: 14 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.33 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + procedure: + - sequence: 1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: principal + date: '2020-08-18' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: B2111ZZ + insurance: + - focal: true + coverage: + display: Part A + item: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '14' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Z + sequence: 1 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0517' + display: CLINIC - FAMILY PRACTICE CLINIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0517' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '3' + display: Charges are not subject to deductible or coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2020-08-04' + quantity: + value: 3.18 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 417.04 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.28 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 32.77 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 3.85 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.67 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.88 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 487.68 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 286.61 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 5.55 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.14 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 0.58 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: R + sequence: 2 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0114' + display: ROOM & BOARD - PRIVATE (ONE BED) - PSYCHIATRIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0114' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2020-08-04' + quantity: + value: 0.03 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1255.42 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.37 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1172.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0.01 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.24 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.26 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.79 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 720.3 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 890.22 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 11.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 10.03 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180032 + quantity: + value: 211.64 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: R + sequence: 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0312' + display: LABORATORY PATHOLOGY - HISTOLOGY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0312' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2020-08-04' + quantity: + value: 1.57 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1419.54 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.96 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 517.28 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.61 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.31 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.06 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.99 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 762.27 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 373.52 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 13.62 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.25 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 8.16 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180031 + quantity: + value: 404.07 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '14' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: B + sequence: 4 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0547' + display: AMBULANCE - PHARMACY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0547' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '0' + display: Charges are subject to deductible and coinsurance + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2020-08-04' + quantity: + value: 4.99 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1331.09 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 862.5 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 4.44 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.32 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.4 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.17 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 460.79 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 897.62 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 1.42 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.31 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 1.37 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180032 + quantity: + value: 223.58 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: H + sequence: 5 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0700' + display: CAST ROOM - GENERAL CLASSIFICATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0700' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '2' + display: Charges are not subject to coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + servicedDate: '2020-08-04' + quantity: + value: 2.09 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 277 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.25 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 370.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.44 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 3.74 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.18 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.56 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 63.58 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1123.03 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 2.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.32 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 3.46 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 590.36 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q2 + sequence: 6 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0141' + display: ROOM & BOARD - DELUXE PRIVATE - MEDICAL/SURGICAL/GYN + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0141' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '0' + display: Charges are subject to deductible and coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2020-08-04' + quantity: + value: 0.8 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 927.16 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.19 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1058.76 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.44 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.32 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.05 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.47 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 439.25 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 4.06 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 4.89 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.75 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 14.34 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 994.85 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q3 + sequence: 7 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '1006' + display: >- + BEHAVIORAL HEALTH ACCOMMODATIONS - OUTDOOR/WILDERNESS + BEHAVIORAL HEALTH (EFFECTIVE 7/1/17) + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '1006' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '4' + display: >- + No charge or units associated with this revenue center code. + (For multiple HCPCS per single revenue center code) For + revenue center code 0001, the following MSP override values + may be present: + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + - system: 'http://www.ama-assn.org/go/cpt' + code: '32' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + servicedDate: '2020-08-04' + quantity: + value: 2.1 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 332.51 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.9 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1310.41 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.23 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.16 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.22 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.13 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 79.94 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 889.3 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 0.99 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.55 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 5.21 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264780020 + quantity: + value: 624.77 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '6' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '4' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '11' + sequence: 8 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0984 + display: >- + PROFESSIONAL FEES (EXTENSION OF 096X AND 097X) - MEDICAL + SOCIAL SERVICES + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0984 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '3' + display: Charges are not subject to deductible or coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2020-08-04' + quantity: + value: 4.78 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 587 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.1 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 98.25 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.33 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.49 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.19 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.02 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1471.64 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 545.07 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 2.36 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.07 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 14.82 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '6' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Z + sequence: 9 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0351' + display: CT SCAN - HEAD SCAN + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0351' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: M + display: >- + Override code; EGHP (employer group health plan) services + involved + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2020-08-04' + quantity: + value: 2.53 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 828.28 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.37 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 35.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.7 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 3.42 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.34 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.42 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1455.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 536.61 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 13.64 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.76 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 11.87 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180032 + quantity: + value: 417.4 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: J1 + sequence: 10 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0339 + display: >- + RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - + OTHER RADIOLOGY - THERAPEUTIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0339 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2020-08-04' + quantity: + value: 3.97 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 980.63 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.14 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1350.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.55 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.27 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.96 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 826.74 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 837.68 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 9.23 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 12.02 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '12' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: P + sequence: 11 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0769 + display: SPECIALTY SERVICES - OTHER SPECIALTY SERVICES + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0769 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: 'N' + display: Override code; non-EGHP services involved + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2020-08-04' + quantity: + value: 3.47 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1263.87 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.22 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 853.67 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.69 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.76 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 4.11 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.36 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 488.99 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 130.12 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 6.73 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.88 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 10.47 + currency: USD + adjudication: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-IP-PPS-DRG-WT-NUM + valueDecimal: 1.14 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator + code: benefitpaymentstatus + display: Benefit Payment Status + reason: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus + code: other + display: Other + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 429788.28125 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 932.21 + currency: USD + payment: + amount: + value: 199095.71 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1584.27 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_COINSRNC_AMT + display: Beneficiary Part A Coinsurance Liability Amount + usedMoney: + value: 8.43 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_BLOOD_LBLTY_AMT + display: Beneficiary Blood Deductible Liability Amount + usedMoney: + value: 2.78 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_NCVRD_CHRG_AMT + display: Inpatient(or other Part A) Non-covered Charge Amount + usedMoney: + value: 230692.56 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_LRD_USE_CNT + display: >- + Beneficiary Medicare Lifetime Reserve Days (LRD) Used + Count + usedUnsignedInt: 4 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HHA_TOT_VISIT_CNT + display: Claim HHA Total Visit Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HOSPC_PRD_CNT + display: Beneficiary's Hospice Period Count. + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_MDCR_COINS_DAY_CNT + display: Beneficiary Total Coinsurance Days Count + usedUnsignedInt: 5 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_CVRD_DAY_CNT + display: Claim Medicare Utilization Day Count + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PER_DIEM_AMT + display: Claim Pass Thru Per Diem Amount + usedMoney: + value: 262.55 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_BENE_PD_AMT + display: >- + The amount paid, from the Medicare trust fund, to the + beneficiary for the services reported on the claim. + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_DSPRPRTNT_AMT + display: Claim PPS Capital Disproportionate Share Amount + usedMoney: + value: 2995.37 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_EXCPTN_AMT + display: Claim PPS Capital Exception Amount + usedMoney: + value: 5.24 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_FSP_AMT + display: Claim PPS Capital Federal Specific Portion (FSP) Amount + usedMoney: + value: 9.15 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_IME_AMT + display: Claim PPS Capital Indirect Medical Education (IME) Amount + usedMoney: + value: 4.52 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_OUTLIER_AMT + display: Claim PPS Capital Outlier Amount + usedMoney: + value: 21.04 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT + display: Claim PPS Old Capital Hold Harmless Amount + usedMoney: + value: 12.99 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_TOT_AMT + display: Claim Total PPS Capital Amount + usedMoney: + value: 4.66 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_PRMRY_PYR_AMT + display: Primary Payer (if not Medicare) Claim Paid Amount + usedMoney: + value: 2918.54 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PRFNL_AMT + display: Professional Component Charge Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_DRG_OUTLIER_AMT + display: DRG Outlier Approved Payment Amount + usedMoney: + value: 1888.9 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_BENE_DDCTBL_AMT + display: Beneficiary Inpatient (or other Part A) Deductible Amount + usedMoney: + value: 5.91 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_HIPPS_UNCOMPD_CARE_AMT + display: Claim Uncompensated Care Payment Amount + usedMoney: + value: 48.36 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_DSPRTNT_AMT + display: Operating Disproportionate Share Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_IME_AMT + display: Operating Indirect Medical Education Amount + usedMoney: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1584.27 + currency: USD + - resource: + resourceType: ExplanationOfBenefit + id: '-5116824090575' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1447692959' + extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + code: ( + display: >- + MSP COST AVOIDED - LIABILITY INSURER VDSA ('16' 2-BYTE CODE) (EFF. + 4/2006) + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM + valueString: '9689' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2019-09-19' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '12301' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-DISP-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD' + code: AB + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: L + display: Assigned Claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-5116824090575' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 76861610318909CUC + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '72' + display: MEDICARE PART B PROFESSIONAL PHYSICIAN/SUPPLIER CLAIM (DMEPOS) + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: professional + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + code: '3' + start: '2019-08-27' + end: '2019-09-19' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: referring + display: Referring provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 1 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD + code: A + - sequence: 3 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: 043O + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD + code: '4' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '43' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: 43O + - sequence: 4 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: O + display: >- + Part B physician/supplier claim record (processed by local + carriers; can include DMEPOS services) + - sequence: 5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: clmrecvddate + timingDate: '2019-09-19' + - sequence: 6 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2019-09-19' + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Z63.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y93.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y93.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E01.70 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W55.41XA + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E01.70 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: secondary + - sequence: 7 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Z63.1 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + insurance: + - focal: true + coverage: + display: Part A + item: + - sequence: 1 + diagnosisSequence: + - 1 + - 7 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0252' + display: >- + PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X) - NON-GENERIC + DRUGS + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0252' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + - system: 'http://www.ama-assn.org/go/cpt' + code: '32' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: 1P + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2019-08-27' + quantity: + value: 2.83 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 130.91 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.08 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 276.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.02 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.78 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.21 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264180032 + quantity: + value: 436.62 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - sequence: 2 + diagnosisSequence: + - 2 + - 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0515' + display: CLINIC - PEDIATRIC CLINIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0515' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + servicedDate: '2019-08-27' + quantity: + value: 0.13 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 786.92 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 853.54 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.11 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 3.79 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.72 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.11 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338011704 + quantity: + value: 307.48 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - sequence: 3 + diagnosisSequence: + - 1 + - 7 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0710' + display: RECOVERY ROOM - GENERAL CLASSIFICATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0710' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + servicedDate: '2019-08-27' + quantity: + value: 3.07 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 898.06 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 1.86 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 195.44 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.26 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.69 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.78 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 532.63 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - sequence: 4 + diagnosisSequence: + - 1 + - 7 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0769 + display: SPECIALTY SERVICES - OTHER SPECIALTY SERVICES + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0769 + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: US + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2019-08-27' + quantity: + value: 4.79 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 562.62 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 4.7 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 105.48 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.62 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.07 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.69 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.24 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338011704 + quantity: + value: 189.61 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 232850.671875 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 915188.6875 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 471241.23 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 6.72 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 212.91 + currency: USD + payment: + amount: + value: 339974.96 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1462.2 + currency: USD + - resource: + resourceType: ExplanationOfBenefit + id: '-5796709164' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1730548868' + - resourceType: Practitioner + id: careteam-provider-2 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1023051596' + - resourceType: Practitioner + id: careteam-provider-3 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1730548868' + - resourceType: Practitioner + id: careteam-provider-4 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1023051596' + extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD + code: '#' + display: >- + MSP COST AVOIDED - OFFICE OF PERSONNEL MANAGEMENT ('13' 2-BYTE + CODE) + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM + valueString: '1483' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2019-04-02' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '52280' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-DISP-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD' + code: '50' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FI-ACTN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD' + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: L + display: Assigned Claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-5796709164' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 85741865389359UYS + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '10' + display: MEDICARE HHA CLAIM + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: institutional + subType: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType + code: inpatient + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + start: '2019-03-08' + end: '2019-04-02' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: attending + display: Attending + - sequence: 2 + provider: + reference: '#careteam-provider-2' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: operating + display: Operating + - sequence: 3 + provider: + reference: '#careteam-provider-3' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: otheroperating + display: Other Operating + - sequence: 4 + provider: + reference: '#careteam-provider-4' + role: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole + code: rendering + display: Rendering provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 0 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD + code: A + - sequence: 3 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: 033X + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD + code: '3' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '33' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: 33X + - sequence: 4 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: U + display: >- + Both Part A and B institutional home health agency (HHA) claim + records + - sequence: 5 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admissionperiod + timingPeriod: + start: '2019-03-08' + end: '2019-04-02' + - sequence: 6 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: clmrecvddate + timingDate: '2019-04-02' + - sequence: 7 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2019-04-02' + - sequence: 8 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: pointoforigin + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PointOfOrigin' + code: U + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD' + code: U + display: RESERVED FOR NATIONAL ASSIGNMENT (NON-NEWBORN) + - sequence: 9 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: discharge-status + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PatDischargeStatus' + code: '88' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD' + code: '88' + display: >- + DISCHARGED/TRANSFERRED TO A FEDERAL HEALTH CARE FACILITY WITH + A PLANNED ACUTE CARE HOSPITAL INPATIENT READMISSION (EFFECTIVE + 10/1/13) + - sequence: 10 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: admtype + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' + code: '8' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD' + code: '8' + - sequence: 11 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_MDCR_INSTNL_MCO_PD_SW + display: MCO Paid Switch + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW + code: '1' + display: MCO paid provider for the claim + - sequence: 12 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType + code: drg + code: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software + code: '28' + - sequence: 13 + category: + coding: + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information + code: CLM_HHA_RFRL_CD + display: Claim Referral Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM_HHA_RFRL_CD' + code: '7' + display: >- + EMERGENCY ROOM - THE PATIENT WAS ADMITTED UPON THE + RECOMMENDATION OF THIS FACILITY'S EMERGENCY ROOM PHYSICIAN. + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y92.311 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: admitting + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y93.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: '0' + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W61.62 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W58.13XD + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: W59.22XA + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 7 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.2 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + - sequence: 8 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.33 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 9 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: V97.2 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: '0' + - sequence: 10 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType + code: externalcauseofinjury + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: Z + - sequence: 11 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: Y93.1 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + procedure: + - sequence: 1 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: principal + date: '2019-03-15' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: 5A09357 + - sequence: 2 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: other + date: '2019-03-17' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: 5A1955Z + - sequence: 3 + type: + - coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType + code: other + date: '2019-03-29' + procedureCodeableConcept: + coding: + - system: 'http://www.cms.gov/Medicare/Coding/ICD10' + code: 5A1955Z + insurance: + - focal: true + coverage: + display: Part A + item: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '6' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q4 + sequence: 1 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0309 + display: LABORATORY - OTHER LABORATORY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0309 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: US + servicedDate: '2019-03-08' + quantity: + value: 4.09 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1435.43 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.52 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1149.64 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.76 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.41 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.48 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 380.64 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1156.28 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 9.07 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.6 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 7.68 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338011704 + quantity: + value: 28.49 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Q4 + sequence: 2 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0826 + display: HEMODIALYSIS - SHORTER DURATION + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0826 + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + servicedDate: '2019-03-08' + quantity: + value: 4.09 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1481.84 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.31 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 750.01 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.74 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.49 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1062.21 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1356.79 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 7.89 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.57 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 10.46 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '7' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: R + sequence: 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0254' + display: >- + PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X) - DRUGS + INCIDENT TO OTHER DIAGNOSTIC SERVICES + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0254' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: M + display: >- + Override code; EGHP (employer group health plan) services + involved + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '32' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + servicedDate: '2019-03-08' + quantity: + value: 2.19 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 683.51 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 4.99 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 116.01 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 4.24 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.11 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.63 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.43 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 932.35 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 486.56 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 9.57 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.7 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.62 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '16' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: Z + sequence: 4 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0157' + display: ROOM & BOARD - WARD - ONCOLOGY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0157' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '4' + display: >- + No charge or units associated with this revenue center code. + (For multiple HCPCS per single revenue center code) For + revenue center code 0001, the following MSP override values + may be present: + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99453' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + servicedDate: '2019-03-08' + quantity: + value: 3.32 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 709.28 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.2 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 584.58 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.5 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0.59 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 3.89 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.84 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 447.3 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1069.2 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 11.72 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.62 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 7.95 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '16' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD + code: X + sequence: 5 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0413' + display: RESPIRATORY SERVICES - HYPERBARIC OXYGEN THERAPY + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0413' + - system: >- + https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD + code: '0' + display: Charges are subject to deductible and coinsurance + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + servicedDate: '2019-03-08' + quantity: + value: 4.07 + adjudication: + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1105.98 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 2.28 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 6.05 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 2.18 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.71 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.9 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 0.89 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: >- + Revenue Center Coinsurance/Wage Adjusted Coinsurance + Amount + amount: + value: 1153.82 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1104.68 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 0.33 + currency: USD + - category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.61 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 14.01 + currency: USD + adjudication: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-IP-PPS-DRG-WT-NUM + valueDecimal: 0.71 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator + code: benefitpaymentstatus + display: Benefit Payment Status + reason: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus + code: other + display: Other + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 825556.25 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 890.26 + currency: USD + payment: + amount: + value: 433277.55 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 185.59 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_COINSRNC_AMT + display: Beneficiary Part A Coinsurance Liability Amount + usedMoney: + value: 2.2 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_BLOOD_LBLTY_AMT + display: Beneficiary Blood Deductible Liability Amount + usedMoney: + value: 16.44 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_NCVRD_CHRG_AMT + display: Inpatient(or other Part A) Non-covered Charge Amount + usedMoney: + value: 392278.68 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_LRD_USE_CNT + display: >- + Beneficiary Medicare Lifetime Reserve Days (LRD) Used + Count + usedUnsignedInt: 7 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HHA_TOT_VISIT_CNT + display: Claim HHA Total Visit Count. + usedUnsignedInt: 5 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HOSPC_PRD_CNT + display: Beneficiary's Hospice Period Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_MDCR_COINS_DAY_CNT + display: Beneficiary Total Coinsurance Days Count + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_CVRD_DAY_CNT + display: Claim Medicare Utilization Day Count + usedUnsignedInt: 6 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PER_DIEM_AMT + display: Claim Pass Thru Per Diem Amount + usedMoney: + value: 63.81 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_BENE_PD_AMT + display: >- + The amount paid, from the Medicare trust fund, to the + beneficiary for the services reported on the claim. + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_DSPRPRTNT_AMT + display: Claim PPS Capital Disproportionate Share Amount + usedMoney: + value: 159.79 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_EXCPTN_AMT + display: Claim PPS Capital Exception Amount + usedMoney: + value: 6.45 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_FSP_AMT + display: Claim PPS Capital Federal Specific Portion (FSP) Amount + usedMoney: + value: 2.69 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_IME_AMT + display: Claim PPS Capital Indirect Medical Education (IME) Amount + usedMoney: + value: 24.49 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_OUTLIER_AMT + display: Claim PPS Capital Outlier Amount + usedMoney: + value: 12.38 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT + display: Claim PPS Old Capital Hold Harmless Amount + usedMoney: + value: 20.5 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_TOT_AMT + display: Claim Total PPS Capital Amount + usedMoney: + value: 0.67 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_PRMRY_PYR_AMT + display: Primary Payer (if not Medicare) Claim Paid Amount + usedMoney: + value: 2398.17 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PRFNL_AMT + display: Professional Component Charge Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_DRG_OUTLIER_AMT + display: DRG Outlier Approved Payment Amount + usedMoney: + value: 1005.75 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_BENE_DDCTBL_AMT + display: Beneficiary Inpatient (or other Part A) Deductible Amount + usedMoney: + value: 23.71 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_HIPPS_UNCOMPD_CARE_AMT + display: Claim Uncompensated Care Payment Amount + usedMoney: + value: 80.16 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_DSPRTNT_AMT + display: Operating Disproportionate Share Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_IME_AMT + display: Operating Indirect Medical Education Amount + usedMoney: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 185.59 + currency: USD + + + V1FhirExplanationOfBenefitByIdExample: + value: + resourceType: ExplanationOfBenefit + id: outpatient--10000930038021 + meta: + lastUpdated: '2023-06-14T12:32:51.430-04:00' + extension: + - url: https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt + valueMoney: + value: 4 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt + valueMoney: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt + valueMoney: + value: 10 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt + valueMoney: + value: 60.7 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt + valueMoney: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am + valueMoney: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd + valueCoding: + system: https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd + - url: https://bluebutton.cms.gov/resources/variables/prpayamt + valueMoney: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - url: https://bluebutton.cms.gov/resources/variables/fi_doc_clm_cntl_num + valueIdentifier: + system: https://bluebutton.cms.gov/resources/variables/fi_doc_clm_cntl_num + value: '-426561283' + identifier: + - system: https://bluebutton.cms.gov/resources/variables/clm_id + value: '-10000930038021' + - system: https://bluebutton.cms.gov/resources/identifier/claim-group + value: '-1632178419' + status: active + type: + coding: + - system: https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd + code: '40' + display: Hospital Outpatient claim + - system: https://bluebutton.cms.gov/resources/codesystem/eob-type + code: OUTPATIENT + - system: http://hl7.org/fhir/ex-claimtype + code: professional + display: Professional + - system: https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd + code: W + display: Part B institutional claim record (outpatient [HOP], HHA) + - system: https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd + code: '3' + patient: + reference: Patient/-10000010254647 + billablePeriod: + extension: + - url: https://bluebutton.cms.gov/resources/variables/claim_query_cd + valueCoding: + system: https://bluebutton.cms.gov/resources/variables/claim_query_cd + code: '3' + display: Final bill + start: '2016-09-13' + end: '2016-09-13' + provider: + identifier: + system: https://bluebutton.cms.gov/resources/variables/prvdr_num + value: '014018' + organization: + identifier: + system: http://hl7.org/fhir/sid/us-npi + value: '1225301823' + display: BEHAVIORAL HEALTHCARE CENTER AT HUNTSVILLE + facility: + extension: + - url: https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd + valueCoding: + system: https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd + code: '1' + display: Hospital + identifier: + system: http://hl7.org/fhir/sid/us-npi + value: '1225301823' + display: BEHAVIORAL HEALTHCARE CENTER AT HUNTSVILLE + information: + - sequence: 1 + category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/information + code: https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt + display: NCH Weekly Claim Processing Date + timingDate: '2016-09-16' + - sequence: 2 + category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/information + code: https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw + display: Claim MCO Paid Switch + code: + coding: + - system: https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw + code: '0' + display: No managed care organization (MCO) payment + - sequence: 3 + category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/information + code: https://bluebutton.cms.gov/resources/variables/clm_freq_cd + display: Claim Frequency Code + code: + coding: + - system: https://bluebutton.cms.gov/resources/variables/clm_freq_cd + code: '1' + display: Admit thru discharge claim + - sequence: 4 + category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/information + code: https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd + display: Patient Discharge Status Code + code: + coding: + - system: https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd + code: '1' + - sequence: 5 + category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/information + code: https://bluebutton.cms.gov/resources/variables/nch_prmry_pyr_cd + display: NCH Primary Payer Code (if not Medicare) + code: + coding: + - system: https://bluebutton.cms.gov/resources/variables/nch_prmry_pyr_cd + careTeam: + - sequence: 2 + provider: + identifier: + system: http://hl7.org/fhir/sid/us-npi + value: '9999987891' + role: + coding: + - system: http://hl7.org/fhir/claimcareteamrole + code: assist + display: Assisting Provider + - sequence: 3 + provider: + identifier: + system: http://hl7.org/fhir/sid/us-npi + value: '9999987891' + role: + coding: + - system: http://hl7.org/fhir/claimcareteamrole + code: primary + display: Primary provider + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: J329 + display: '"CHRONIC SINUSITIS, UNSPECIFIED"' + type: + - coding: + - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type + code: principal + display: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: B9789 + display: OTH VIRAL AGENTS AS THE CAUSE OF DISEASES CLASSD ELSWHR + type: + - coding: + - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type + code: principal + display: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: Z608 + display: OTHER PROBLEMS RELATED TO SOCIAL ENVIRONMENT + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: M5450 + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: M797 + display: FIBROMYALGIA + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: Z733 + display: '"STRESS, NOT ELSEWHERE CLASSIFIED"' + - sequence: 7 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: Z560 + display: '"UNEMPLOYMENT, UNSPECIFIED"' + - sequence: 8 + diagnosisCodeableConcept: + coding: + - system: http://hl7.org/fhir/sid/icd-10 + code: Y93 + display: ACTIVITY CODES + type: + - coding: + - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type + code: external-first + display: The code used to identify the 1st external cause of injury, poisoning, or other adverse effect. + - sequence: 9 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/unknown-icd-version/ ' + type: + - coding: + - system: https://bluebutton.cms.gov/resources/codesystem/diagnosis-type + code: external + display: A code used to identify an external cause of injury, poisoning, or other adverse effect. + insurance: + coverage: + reference: Coverage/part-b--10000010254647 + item: + - sequence: 1 + careTeamLinkId: + - 3 + revenue: + extension: + - url: https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd + valueCoding: + system: https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd + code: '4' + coding: + - system: https://bluebutton.cms.gov/resources/variables/rev_cntr + code: '0001' + display: Total charge + service: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/hcpcs + code: '99241' + servicedDate: '2016-09-13' + locationAddress: + state: '01' + quantity: + value: 1 + adjudication: + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt + display: Revenue Center Blood Deductible Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt + display: Revenue Center Cash Deductible Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c + display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt + display: Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt + display: Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt + display: Revenue Center (Medicare) Provider Payment Amount + amount: + value: 60.7 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: + - system: https://bluebutton.cms.gov/resources/codesystem/adjudication + code: https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt + display: Revenue Center (Medicare) Payment Amount + amount: + value: 60.7 + system: urn:iso:std:iso:4217 + code: USD + - category: + coding: - system: https://bluebutton.cms.gov/resources/codesystem/adjudication code: https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt display: Revenue Center Rate Amount @@ -34900,6 +45417,1459 @@ components: system: 'urn:iso:std:iso:4217' code: USD + V3FhirExplanationOfBenefitByIdExample: + value: + resourceType: ExplanationOfBenefit + id: '-9631024438695' + meta: + lastUpdated: '2025-11-24T22:11:11.548+00:00' + source: NationalClaimsHistory + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.1.0 + tag: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication-Status' + code: Adjudicated + contained: + - resourceType: Organization + id: insurer-org + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|6.1.0 + active: true + name: Centers for Medicare and Medicaid Services + - resourceType: Practitioner + id: careteam-provider-1 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1558719914' + - resourceType: Practitioner + id: careteam-provider-2 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1447692959' + - resourceType: Practitioner + id: careteam-provider-3 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1942945159' + - resourceType: Practitioner + id: careteam-provider-4 + meta: + profile: + - >- + http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Practitioner|2.1.0 + - >- + http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|6.1.0 + identifier: + - type: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/v2-0203' + code: NPI + display: National provider identifier + system: 'http://hl7.org/fhir/sid/us-npi' + value: '1437702123' + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CARR-PMT-DNL-CD' + code: 'N' + display: MEDICAL NECESSITY + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CLNCL-TRIL-NUM' + valueString: '6056' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CMS-PROC-DT' + valueDate: '2018-11-03' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-CNTRCTR-NUM' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-CNTRCTR-NUM' + code: '14312' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-DISP-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DISP-CD' + code: '58' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-FI-ACTN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-FI-ACTN-CD' + code: '1' + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-NPMT-RSN-CD' + code: T + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + valueCoding: + system: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-PRFNL-PRVDR-ASGNMT-SW + code: L + display: Assigned Claim + identifier: + - type: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType' + code: uc + display: Unique Claim ID + value: '-9631024438695' + - system: 'https://bluebutton.cms.gov/identifiers/CLM-CNTL-NUM' + value: 24550267688014LFN + status: active + type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-TYPE-CD' + code: '10' + display: MEDICARE HHA CLAIM + - system: 'http://terminology.hl7.org/CodeSystem/claim-type' + code: institutional + subType: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType' + code: inpatient + use: claim + patient: + reference: Patient/-206068516 + billablePeriod: + extension: + - url: 'https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-QUERY-CD' + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-QUERY-CD' + code: '1' + start: '2018-10-27' + end: '2018-11-03' + created: '2025-11-18T00:00:00+00:00' + insurer: + reference: '#insurer-org' + outcome: complete + careTeam: + - sequence: 1 + provider: + reference: '#careteam-provider-1' + role: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole' + code: attending + display: Attending + - sequence: 2 + provider: + reference: '#careteam-provider-2' + role: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole' + code: operating + display: Operating + - sequence: 3 + provider: + reference: '#careteam-provider-3' + role: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole' + code: otheroperating + display: Other Operating + - sequence: 4 + provider: + reference: '#careteam-provider-4' + role: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole' + code: rendering + display: Rendering provider + supportingInfo: + - sequence: 1 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_BLOOD_PT_FRNSH_QTY + display: Blood Pints Furnished Quantity + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + valueQuantity: + value: 0 + unit: pint + system: 'http://unitsofmeasure.org' + code: '[pt_us]' + - sequence: 2 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_NCH_PRMRY_PYR_CD + display: NCH Primary Payer Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NCH-PRMRY-PYR-CD' + code: D + - sequence: 3 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: typeofbill + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/TypeOfBill' + code: '0137' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FAC-TYPE-CD' + code: '1' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-CLSFCTN-CD' + code: '13' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-BILL-FREQ-CD' + code: '137' + - sequence: 4 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_NRLN_RIC_CD + display: Near Line Record Identification Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-NRLN-RIC-CD' + code: U + display: >- + Both Part A and B institutional home health agency (HHA) claim + records + - sequence: 5 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: admissionperiod + timingPeriod: + start: '2018-10-27' + end: '2018-11-03' + - sequence: 6 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: clmrecvddate + timingDate: '2018-11-03' + - sequence: 7 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_NCH_WKLY_PROC_DT + display: Weekly Process Date + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + timingDate: '2018-11-03' + - sequence: 8 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: pointoforigin + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PointOfOrigin' + code: S + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-SRC-CD' + code: S + display: RESERVED FOR NATIONAL ASSIGNMENT (NON-NEWBORN) + - sequence: 9 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: discharge-status + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PatDischargeStatus' + code: '37' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/BENE-PTNT-STUS-CD' + code: '37' + display: RESERVED FOR NATIONAL ASSIGNMENT + - sequence: 10 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: admtype + code: + coding: + - system: 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' + code: '4' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-ADMSN-TYPE-CD' + code: '4' + - sequence: 11 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_MDCR_INSTNL_MCO_PD_SW + display: MCO Paid Switch + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-MDCR-INSTNL-MCO-PD-SW' + code: '1' + display: MCO paid provider for the claim + - sequence: 12 + category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType' + code: drg + code: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software + code: '11' + - sequence: 13 + category: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Supporting-Information' + code: CLM_HHA_RFRL_CD + display: Claim Referral Code + - system: 'http://terminology.hl7.org/CodeSystem/claiminformationcategory' + code: info + display: Information + code: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM_HHA_RFRL_CD' + code: '7' + display: >- + EMERGENCY ROOM - THE PATIENT WAS ADMITTED UPON THE RECOMMENDATION OF + THIS FACILITY'S EMERGENCY ROOM PHYSICIAN. + diagnosis: + - sequence: 1 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E11.69 + type: + - coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType' + code: externalcauseofinjury + - sequence: 2 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.5 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: admitting + - sequence: 3 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType' + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: W + - sequence: 4 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType' + code: other + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: '0' + - sequence: 5 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: E11.69 + type: + - coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType' + code: externalcauseofinjury + onAdmission: + coding: + - system: >- + https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding + code: U + - sequence: 6 + diagnosisCodeableConcept: + coding: + - system: 'http://hl7.org/fhir/sid/icd-10-cm' + code: R46.1 + type: + - coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype' + code: principal + insurance: + - focal: true + coverage: + display: Part A + item: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-DSCNT-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-DSCNT-IND-CD' + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD' + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '16' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD' + code: E + sequence: 1 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0963 + display: PROFESSIONAL FEES (ALSO SEE 097X AND 098X) - ANESTHESIOLOGIST (MD) + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0963 + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD' + code: '2' + display: Charges are not subject to coinsurance + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: U6 + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2018-10-27' + quantity: + value: 2.9 + adjudication: + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 572.55 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.72 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1190.09 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.11 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.33 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.07 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 3.25 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount + amount: + value: 226.47 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 534.34 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 12.6 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 0.29 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 6.12 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00264780020 + quantity: + value: 474.2 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'Y' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD' + code: '2' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '13' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD' + code: U + sequence: 2 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0641' + display: 'HOME IV THERAPY SERVICES - NON-ROUTINE NURSING, CENTRAL LINE' + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0641' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD' + code: 'N' + display: Override code; non-EGHP services involved + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + servicedDate: '2018-10-27' + quantity: + value: 2.41 + adjudication: + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 242.23 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 3.4 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 415.56 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 3.24 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 2.94 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 1.78 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 2.18 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount + amount: + value: 340.47 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 491.71 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 2.03 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.01 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 1.57 + currency: USD + detail: + - sequence: 1 + productOrService: + coding: + - system: 'http://hl7.org/fhir/sid/ndc' + code: 00338004904 + quantity: + value: 831.67 + unit: ML + system: 'http://unitsofmeasure.org' + code: mL + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-OTAF-ONE-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-OTAF-ONE-IND-CD' + code: 'N' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD' + code: '3' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '5' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD' + code: H + sequence: 3 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: 0695 + display: >- + PRE-HOSPICE/PALLIATIVE CARE SERVICES - INPATIENT CARE (EFFECTIVE + 1/1/14) + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: 0695 + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD' + code: '1' + display: Charges are not subject to deductible + productOrService: + coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: J2270 + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PD + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '23' + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: US + servicedDate: '2018-10-27' + quantity: + value: 2.41 + adjudication: + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 508.27 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.29 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 1273.41 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.7 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 4.97 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 2.29 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 4.24 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount + amount: + value: 1341.09 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 726.73 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 8.24 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.21 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.26 + currency: USD + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PACKG-IND-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PACKG-IND-CD' + code: '1' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-PMT-MTHD-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-PMT-MTHD-CD' + code: '8' + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-REV-CNTR-STUS-CD + valueCoding: + system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-STUS-CD' + code: M + sequence: 4 + revenue: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-REV-CNTR-CD' + code: '0133' + display: ROOM & BOARD - SEMI-PRIVATE - THREE AND FOUR BEDS - PEDIATRIC + - system: 'https://www.nubc.org/CodeSystem/RevenueCodes' + code: '0133' + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/CLM-DDCTBL-COINSRNC-CD' + code: X + display: 'Override code: MSP (Medicare is secondary payer) cost avoided' + productOrService: + coding: + - system: 'http://www.ama-assn.org/go/cpt' + code: '99213' + modifier: + - coding: + - system: 'https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets' + code: PC + - system: 'http://www.ama-assn.org/go/cpt' + code: '28' + - system: 'http://www.ama-assn.org/go/cpt' + code: '22' + servicedDate: '2018-10-27' + quantity: + value: 4.21 + adjudication: + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: noncovered + display: Noncovered + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_NCVRD_CHRG_AMT + display: Revenue Center Non-Covered Charge Amount + amount: + value: 1453.68 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Eligible Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_ALOWD_CHRG_AMT + display: Line Allowed Charge Amount + amount: + value: 0.53 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_PRVDR_PMT_AMT + display: Line Provider Payment Amount + amount: + value: 395.11 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 1.4 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtopatient + display: Paid to patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_BENE_PD_AMT + display: Revenue Center Payment Amount to Beneficiary + amount: + value: 1.72 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: benefit + display: Benefit Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_CVRD_PD_AMT + display: Revenue Center Payment Amount + amount: + value: 0.38 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: deductible + display: Deductible + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_MDCR_DDCTBL_AMT + display: Revenue Center Cash Deductible Amount + amount: + value: 1.34 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_ADJSTD_AMT + display: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount + amount: + value: 1042.1 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: coinsurance + display: Co-insurance + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RDCD_AMT + display: Revenue Center Reduced Coinsurance Amount + amount: + value: 1486.08 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP1_PD_AMT + display: Revenue Center 1st MSP Paid Amount + amount: + value: 14.26 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: priorpayerpaid + display: Prior payer paid + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_MSP2_PD_AMT + display: Revenue Center 2nd MSP Paid Amount + amount: + value: 1.03 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_LINE_INSTNL_RATE_AMT + display: Revenue Center Rate Amount + amount: + value: 9.71 + currency: USD + adjudication: + - extension: + - url: >- + https://bluebutton.cms.gov/fhir/StructureDefinition/CLM-MDCR-IP-PPS-DRG-WT-NUM + valueDecimal: 0.67 + category: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator + code: benefitpaymentstatus + display: Benefit Payment Status + reason: + coding: + - system: >- + http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus + code: other + display: Other + total: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: eligible + display: Allowed Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_ALOWD_CHRG_AMT + display: Total Allowed Charge Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/adjudication' + code: submitted + display: Submitted Amount + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_SBMT_CHRG_AMT + display: Total Submitted Charge Amount + amount: + value: 99816.1171875 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidbypatient + display: Paid by patient + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_BENE_PMT_AMT + display: Revenue Center Patient Responsibility Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_PRVDR_PMT_AMT + display: Provider Payment Amount + amount: + value: 0 + currency: USD + - category: + coding: + - system: 'http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' + code: paidtoprovider + display: Paid to provider + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' + code: CLM_MDCR_PRFNL_PRMRY_PYR_AMT + display: Primary Payer Paid Amount + amount: + value: 968.73 + currency: USD + payment: + amount: + value: 17103.19 + currency: USD + benefitBalance: + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1382.05 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_COINSRNC_AMT + display: Beneficiary Part A Coinsurance Liability Amount + usedMoney: + value: 24.88 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_BLOOD_LBLTY_AMT + display: Beneficiary Blood Deductible Liability Amount + usedMoney: + value: 20.8 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_NCVRD_CHRG_AMT + display: Inpatient(or other Part A) Non-covered Charge Amount + usedMoney: + value: 82712.93 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_LRD_USE_CNT + display: Beneficiary Medicare Lifetime Reserve Days (LRD) Used Count + usedUnsignedInt: 3 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HHA_TOT_VISIT_CNT + display: Claim HHA Total Visit Count. + usedUnsignedInt: 18 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_HOSPC_PRD_CNT + display: Beneficiary's Hospice Period Count. + usedUnsignedInt: 0 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_MDCR_COINS_DAY_CNT + display: Beneficiary Total Coinsurance Days Count + usedUnsignedInt: 1 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_CVRD_DAY_CNT + display: Claim Medicare Utilization Day Count + usedUnsignedInt: 1 + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PER_DIEM_AMT + display: Claim Pass Thru Per Diem Amount + usedMoney: + value: 119.41 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_BENE_PD_AMT + display: >- + The amount paid, from the Medicare trust fund, to the + beneficiary for the services reported on the claim. + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_DSPRPRTNT_AMT + display: Claim PPS Capital Disproportionate Share Amount + usedMoney: + value: 3187.83 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_EXCPTN_AMT + display: Claim PPS Capital Exception Amount + usedMoney: + value: 7.74 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_FSP_AMT + display: Claim PPS Capital Federal Specific Portion (FSP) Amount + usedMoney: + value: 11.79 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_IME_AMT + display: Claim PPS Capital Indirect Medical Education (IME) Amount + usedMoney: + value: 4.58 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_OUTLIER_AMT + display: Claim PPS Capital Outlier Amount + usedMoney: + value: 10.62 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT + display: Claim PPS Old Capital Hold Harmless Amount + usedMoney: + value: 10.54 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_PPS_CPTL_TOT_AMT + display: Claim Total PPS Capital Amount + usedMoney: + value: 11.93 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_INSTNL_PRMRY_PYR_AMT + display: Primary Payer (if not Medicare) Claim Paid Amount + usedMoney: + value: 2130.46 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_PRFNL_AMT + display: Professional Component Charge Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_INSTNL_DRG_OUTLIER_AMT + display: DRG Outlier Approved Payment Amount + usedMoney: + value: 1105.4 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_IP_BENE_DDCTBL_AMT + display: Beneficiary Inpatient (or other Part A) Deductible Amount + usedMoney: + value: 21.44 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_HIPPS_UNCOMPD_CARE_AMT + display: Claim Uncompensated Care Payment Amount + usedMoney: + value: 25.85 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_DSPRTNT_AMT + display: Operating Disproportionate Share Amount + usedMoney: + value: 0 + currency: USD + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_OPRTNL_IME_AMT + display: Operating Indirect Medical Education Amount + usedMoney: + value: 0 + currency: USD + - category: + coding: + - system: 'http://terminology.hl7.org/CodeSystem/ex-benefitcategory' + code: '1' + display: Medical Care + financial: + - type: + coding: + - system: 'https://bluebutton.cms.gov/fhir/CodeSystem/Benefit-Balance' + code: CLM_MDCR_DDCTBL_AMT + display: Beneficiary Part B Deductible Amount + usedMoney: + value: 1382.05 + currency: USD servers: