CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: EOB Pharmacy Example1 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ExplanationOfBenefit ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "EOBPharmacy1"] ; # 
  fhir:meta [
fhir:lastUpdated [ fhir:v "2019-12-12T09:14:11+00:00"^^xsd:dateTime ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|2.0.0>     ] )
  ] ; # 
  fhir:language [ fhir:v "en-US"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBPharmacy1\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ExplanationOfBenefit &quot;EOBPharmacy1&quot; Updated &quot;2019-12-12 09:14:11+0000&quot;  (Language &quot;en-US&quot;) </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Pharmacy.html\">C4BB ExplanationOfBenefit Pharmacy (version 2.0.0)</a></p></div><p><b>identifier</b>: Unique Claim ID: AW123412341234123412341234123412</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient2.html\">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>billablePeriod</b>: 2019-10-30 --&gt; 2019-10-31</p><p><b>created</b>: 2019-07-02 00:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">Organization/Payer1: XXX Health Plan</a> &quot;Organization Payer 1&quot;</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1: XXX Health Plan</a> &quot;Orange Medical Group&quot;</p><p><b>outcome</b>: partial</p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Days Supply <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#dayssupply)</span></p><p><b>value</b>: 30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: DAW (Dispense As Written) Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#dawcode)</span></p><p><b>code</b>: 7 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-NCPDPDispensedAsWrittenOrProductSelectionCode.html\">NCPDP Dispense As Written (DAW)/Product Selection Code</a>#7)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Refill Number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#refillnum)</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Refills Authorized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#refillsauthorized)</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Brand Generic Indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#brandgenericindicator)</span></p><p><b>code</b>: 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-NCPDPBrandGenericIndicator.html\">NCPDP Brand Generic Indicator</a>#2)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Rx Origin Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#rxorigincode)</span></p><p><b>code</b>: 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-NCPDPPrescriptionOriginCode.html\">NCPDP Prescription Origin Code</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Claim Received Date <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#clmrecvddate)</span></p><p><b>timing</b>: 2019-10-31</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: Compound Code <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#compoundcode)</span></p><p><b>code</b>: Dummy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-NCPDPCompoundCode.html\">NCPDP Compound Code</a>#Dummy)</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-Coverage3.html\">Coverage/Coverage3</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-v3-ndc.html\">National drug codes</a>#0777-3105-02)</span></p><p><b>serviced</b>: 2019-07-02</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1000</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#discount)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>900</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Member liability <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#memberliability)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>80</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Paid to provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td>Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr><tr><td style=\"display: none\">*</td><td>Billing Network Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: Payment Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidtoprovider)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>620</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2650</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Pay Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#paidbypatient)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
  ] ; # 
  fhir:identifier ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "uc" ]       ] )     ] ;
fhir:system [ fhir:v "https://www.xxxplan.com/fhir/EOBIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "AW123412341234123412341234123412" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "pharmacy" ]     ] ) ;
fhir:text [ fhir:v "Pharmacy" ]
  ] ; # 
  fhir:use [ fhir:v "claim"] ; # 
  fhir:patient [
fhir:reference [ fhir:v "Patient/Patient2" ]
  ] ; # 
  fhir:billablePeriod [
fhir:start [ fhir:v "2019-10-30"^^xsd:date ] ;
fhir:end [ fhir:v "2019-10-31"^^xsd:date ]
  ] ; # 
  fhir:created [ fhir:v "2019-07-02T00:00:00+00:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:reference [ fhir:v "Organization/Payer1" ] ;
fhir:display [ fhir:v "XXX Health Plan" ]
  ] ; # 
  fhir:provider [
fhir:reference [ fhir:v "Organization/ProviderOrganization1" ] ;
fhir:display [ fhir:v "XXX Health Plan" ]
  ] ; # 
  fhir:outcome [ fhir:v "partial"] ; # 
  fhir:supportingInfo ( [
fhir:sequence [ fhir:v "8"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "dayssupply" ]       ] )     ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "30"^^xsd:decimal ]     ]
  ] [
fhir:sequence [ fhir:v "6"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "dawcode" ]       ] )     ] ;
fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPDispensedAsWrittenOrProductSelectionCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "7" ]       ] )     ]
  ] [
fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "refillnum" ]       ] )     ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "0"^^xsd:decimal ]     ]
  ] [
fhir:sequence [ fhir:v "5"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "refillsauthorized" ]       ] )     ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "0"^^xsd:decimal ]     ]
  ] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "brandgenericindicator" ]       ] )     ] ;
fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPBrandGenericIndicator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]       ] )     ]
  ] [
fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "rxorigincode" ]       ] )     ] ;
fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPPrescriptionOriginCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1" ]       ] )     ]
  ] [
fhir:sequence [ fhir:v "7"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "clmrecvddate" ]       ] )     ] ;
fhir:timing [ fhir:v "2019-10-31"^^xsd:date ]
  ] [
fhir:sequence [ fhir:v "9"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "compoundcode" ]       ] )     ] ;
fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/NCPDPCompoundCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "Dummy" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/Coverage3" ]     ]
  ] ) ; # 
  fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/ndc"^^xsd:anyURI ] ;
fhir:code [ fhir:v "0777-3105-02" ] ;
fhir:display [ fhir:v "Prozac, 100 CAPSULE in 1 BOTTLE (0777-3105-02) (package)" ]       ] )     ] ;
fhir:serviced [ fhir:v "2019-07-02"^^xsd:date ] ;
    ( fhir:adjudication [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "1000"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefit" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "discount" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "900"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "memberliability" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "80"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidtoprovider" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "20"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] )
  ] ) ; # 
  fhir:adjudication ( [
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "benefitpaymentstatus" ]       ] )     ] ;
fhir:reason [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ]       ] )     ]
  ] [
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"^^xsd:anyURI ] ;
fhir:code [ fhir:v "billingnetworkstatus" ]       ] )     ] ;
fhir:reason [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"^^xsd:anyURI ] ;
fhir:code [ fhir:v "innetwork" ]       ] )     ]
  ] ) ; # 
  fhir:total ( [
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidtoprovider" ]       ] ) ;
fhir:text [ fhir:v "Payment Amount" ]     ] ;
fhir:amount [
fhir:value [ fhir:v "620"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ]       ] ) ;
fhir:text [ fhir:v "Submitted Amount" ]     ] ;
fhir:amount [
fhir:value [ fhir:v "2650"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "paidbypatient" ]       ] ) ;
fhir:text [ fhir:v "Patient Pay Amount" ]     ] ;
fhir:amount [
fhir:value [ fhir:v "0"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] ) . #