CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.0.0 - STU1

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Example ExplanationOfBenefit: EOB Inpatient Institutional - Example 1

Generated Narrative

identifier: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1

status: active

type: Institutional

use: claim

patient: Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; unknown

billablePeriod: 2017-05-23 --> 2017-05-23

created: Jun 1, 2017, 4:00:00 AM

insurer: UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; Payer; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762

provider: Generated Summary: National Provider Identifier: 3334445550; active; name: Green Medical Group

Payees

-TypeParty
*Any benefit payable will be paid to the provider (Assignment of Benefit).Generated Summary: National Provider Identifier: 4445556660; active; name: Blue Medical Group

outcome: complete

careTeam

sequence: 1

provider: Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown

role: The attending physician

careTeam

sequence: 2

provider: Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown

role: The referring physician

supportingInfo

sequence: 1

category: Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.

code: Indicates the provider was contracted for the service

supportingInfo

sequence: 2

category: Date the claim was received by the payer.

timing: 2017-06-01

supportingInfo

sequence: 3

category: Dates corresponding with the admission and discharge of the beneficiary to a facility

timing: 2017-05-23 --> (ongoing)

diagnosis

sequence: 1

diagnosis: I21.4

type: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.

diagnosis

sequence: 2

diagnosis: I25.118

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 3

diagnosis: E78.5

type: Required when other conditions coexist or develop subsequently during the treatment

diagnosis

sequence: 4

diagnosis: M19.90

type: Required when other conditions coexist or develop subsequently during the treatment

procedure

sequence: 1

type: The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis

date: 2017-05-23

procedure: 4A023N7

procedure

sequence: 2

type: Other procedures performed during the inpatient institutional admission

date: 2017-05-23

procedure: B211YZZ

procedure

sequence: 3

type: Other procedures performed during the inpatient institutional admission

date: 2017-05-23

procedure: B215YZZ

Insurances

-FocalCoverage
*trueGenerated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status: active; subscriberId: 888009335; dependent: 01; Self; period: 2017-01-01 --> 2017-06-30; network: GI8-HMO DEDUCTIBLE

item

sequence: 1

revenue: 0301

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 2

revenue: 0260

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 3

revenue: 0305

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 4

revenue: 0324

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 5

revenue: 0259

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 6

revenue: 0250

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 7

revenue: 0710

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 8

revenue: 0210

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 9

revenue: 0272

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 10

revenue: 0370

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 11

revenue: 0730

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 12

revenue: 0450

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

item

sequence: 13

revenue: 0481

productOrService: 99231

serviced: 2017-05-23 --> (ongoing)

location: HOSPITAL - INPATIENT HOSPITAL

adjudication

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

adjudication

category: Patient Co-Payment

Amounts

-
*

adjudication

category: Amount of the change which is considered for adjudication.

Amounts

-
*

adjudication

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

adjudication

category: Amount payable under the coverage

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

adjudication

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

total

category: The total submitted amount for the claim or group or line item.

Amounts

-
*

total

category: Amount of the change which is considered for adjudication.

Amounts

-
*

total

category: Amount deducted from the eligible amount prior to adjudication.

Amounts

-
*

total

category: Patient Co-Payment

Amounts

-
*

total

category: The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

Amounts

-
*

total

category: Amount payable under the coverage

Amounts

-
*

total

category: The amount of the member's liability.

Amounts

-
*

Notes:

FieldValue
resourceType "ExplanationOfBenefit"
id "InpatientEOBExample1"
meta.lastUpdated "2020-04-28T15:39:36-04:00"
meta.source "Organization/PayerOrganizationExample1"
meta.profile[0]"http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"
identifier[0].type.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"
identifier[0].type.coding[0].code #uc
identifier[0].type.coding[0].display "Unique Claim ID"
identifier[0].type.text "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"
identifier[0].system "https://www.upmchealthplan.com/fhir/EOBIdentifier"
identifier[0].value InpatientEOBExample1
status "active"
type.coding[0].system "http://terminology.hl7.org/CodeSystem/claim-type"
type.coding[0].code #institutional
type.text "Institutional"
use "claim"
patient.reference "Patient/ExamplePatient1"
billablePeriod.start "2017-05-23"
billablePeriod.end "2017-05-23"
created "2017-06-01T00:00:00-04:00"
insurer.reference "Organization/PayerOrganizationExample1"
insurer.display "UPMC Health Plan"
provider.reference "Organization/ProviderOrganization3"
payee.type.coding[0].system "http://terminology.hl7.org/CodeSystem/payeetype"
payee.type.coding[0].code #provider
payee.type.coding[0].display "Provider"
payee.type.text "Any benefit payable will be paid to the provider (Assignment of Benefit)."
payee.party.reference "Organization/ProviderOrganization4"
outcome "complete"
careTeam[0].sequence 1
careTeam[0].provider.reference "Practitioner/Practitioner2"
careTeam[0].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[0].role.coding[0].code #attending
careTeam[0].role.coding[0].display "Attending"
careTeam[0].role.text "The attending physician"
careTeam[1].sequence 2
careTeam[1].provider.reference "Practitioner/Practitioner2"
careTeam[1].role.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"
careTeam[1].role.coding[0].code #referring
careTeam[1].role.coding[0].display "Referring"
careTeam[1].role.text "The referring physician"
supportingInfo[0].sequence 1
supportingInfo[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[0].category.coding[0].code #billingnetworkcontractingstatus
supportingInfo[0].category.coding[0].display "Billing Network Contracting Status"
supportingInfo[0].category.text "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."
supportingInfo[0].code.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"
supportingInfo[0].code.coding[0].code #contracted
supportingInfo[0].code.coding[0].display "Contracted"
supportingInfo[0].code.text "Indicates the provider was contracted for the service"
supportingInfo[1].sequence 2
supportingInfo[1].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[1].category.coding[0].code #clmrecvddate
supportingInfo[1].category.coding[0].display "Claim Received Date"
supportingInfo[1].category.text "Date the claim was received by the payer."
supportingInfo[1].timingDate "2017-06-01"
supportingInfo[2].sequence 3
supportingInfo[2].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"
supportingInfo[2].category.coding[0].code #admissionperiod
supportingInfo[2].category.coding[0].display "Admission Period"
supportingInfo[2].category.text "Dates corresponding with the admission and discharge of the beneficiary to a facility"
supportingInfo[2].timingPeriod.start "2017-05-23"
diagnosis[0].sequence 1
diagnosis[0].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[0].diagnosisCodeableConcept.coding[0].code #I21.4
diagnosis[0].type[0].coding[0].system "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"
diagnosis[0].type[0].coding[0].code #principal
diagnosis[0].type[0].coding[0].display "Principal Diagnosis"
diagnosis[0].type[0].text "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment."
diagnosis[1].sequence 2
diagnosis[1].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[1].diagnosisCodeableConcept.coding[0].code #I25.118
diagnosis[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[1].type[0].coding[0].code #other
diagnosis[1].type[0].coding[0].display "Other"
diagnosis[1].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[2].sequence 3
diagnosis[2].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[2].diagnosisCodeableConcept.coding[0].code #E78.5
diagnosis[2].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[2].type[0].coding[0].code #other
diagnosis[2].type[0].coding[0].display "Other"
diagnosis[2].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
diagnosis[3].sequence 4
diagnosis[3].diagnosisCodeableConcept.coding[0].system "http://hl7.org/fhir/sid/icd-10-cm"
diagnosis[3].diagnosisCodeableConcept.coding[0].code #M19.90
diagnosis[3].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"
diagnosis[3].type[0].coding[0].code #other
diagnosis[3].type[0].coding[0].display "Other"
diagnosis[3].type[0].text "Required when other conditions coexist or develop subsequently during the treatment"
procedure[0].sequence 1
procedure[0].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[0].type[0].coding[0].code #principal
procedure[0].type[0].coding[0].display "Principal"
procedure[0].type[0].text "The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"
procedure[0].date "2017-05-23"
procedure[0].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[0].procedureCodeableConcept.coding[0].code #4A023N7
procedure[1].sequence 2
procedure[1].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[1].type[0].coding[0].code #other
procedure[1].type[0].coding[0].display "Other"
procedure[1].type[0].text "Other procedures performed during the inpatient institutional admission"
procedure[1].date "2017-05-23"
procedure[1].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[1].procedureCodeableConcept.coding[0].code #B211YZZ
procedure[2].sequence 3
procedure[2].type[0].coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"
procedure[2].type[0].coding[0].code #other
procedure[2].type[0].coding[0].display "Other"
procedure[2].type[0].text "Other procedures performed during the inpatient institutional admission"
procedure[2].date "2017-05-23"
procedure[2].procedureCodeableConcept.coding[0].system "http://www.cms.gov/Medicare/Coding/ICD10"
procedure[2].procedureCodeableConcept.coding[0].code #B215YZZ
insurance[0].focal "true"
insurance[0].coverage.reference "Coverage/CoverageEx2"
item[0].sequence 1
item[0].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[0].revenue.coding[0].code #0301
item[0].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[0].productOrService.coding[0].code #99231
item[0].servicedPeriod.start "2017-05-23"
item[0].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[0].locationCodeableConcept.coding[0].code #21
item[0].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[0].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[0].category.coding[0].code #submitted
item[0].adjudication[0].category.coding[0].display "Submitted Amount"
item[0].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[0].adjudication[0].amount.value 386.5
item[0].adjudication[0].amount.currency #USD
item[0].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[1].category.coding[0].code #copay
item[0].adjudication[1].category.coding[0].display "CoPay"
item[0].adjudication[1].category.text "Patient Co-Payment"
item[0].adjudication[1].amount.value 0.0
item[0].adjudication[1].amount.currency #USD
item[0].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[2].category.coding[0].code #eligible
item[0].adjudication[2].category.coding[0].display "Eligible Amount"
item[0].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[0].adjudication[2].amount.value 0.0
item[0].adjudication[2].amount.currency #USD
item[0].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[3].category.coding[0].code #deductible
item[0].adjudication[3].category.coding[0].display "Deductible"
item[0].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[0].adjudication[3].amount.value 0.0
item[0].adjudication[3].amount.currency #USD
item[0].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[0].adjudication[4].category.coding[0].code #benefit
item[0].adjudication[4].category.coding[0].display "Benefit Amount"
item[0].adjudication[4].category.text "Amount payable under the coverage"
item[0].adjudication[4].amount.value 0.0
item[0].adjudication[4].amount.currency #USD
item[0].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[0].adjudication[5].category.coding[0].code #noncovered
item[0].adjudication[5].category.coding[0].display "Noncovered"
item[0].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[0].adjudication[5].amount.value 0.0
item[0].adjudication[5].amount.currency #USD
item[1].sequence 2
item[1].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[1].revenue.coding[0].code #0260
item[1].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[1].productOrService.coding[0].code #99231
item[1].servicedPeriod.start "2017-05-23"
item[1].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[1].locationCodeableConcept.coding[0].code #21
item[1].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[1].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[0].category.coding[0].code #submitted
item[1].adjudication[0].category.coding[0].display "Submitted Amount"
item[1].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[1].adjudication[0].amount.value 322.4
item[1].adjudication[0].amount.currency #USD
item[1].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[1].category.coding[0].code #copay
item[1].adjudication[1].category.coding[0].display "CoPay"
item[1].adjudication[1].category.text "Patient Co-Payment"
item[1].adjudication[1].amount.value 0.0
item[1].adjudication[1].amount.currency #USD
item[1].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[2].category.coding[0].code #eligible
item[1].adjudication[2].category.coding[0].display "Eligible Amount"
item[1].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[1].adjudication[2].amount.value 0.0
item[1].adjudication[2].amount.currency #USD
item[1].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[3].category.coding[0].code #deductible
item[1].adjudication[3].category.coding[0].display "Deductible"
item[1].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[1].adjudication[3].amount.value 0.0
item[1].adjudication[3].amount.currency #USD
item[1].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[1].adjudication[4].category.coding[0].code #benefit
item[1].adjudication[4].category.coding[0].display "Benefit Amount"
item[1].adjudication[4].category.text "Amount payable under the coverage"
item[1].adjudication[4].amount.value 0.0
item[1].adjudication[4].amount.currency #USD
item[1].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[1].adjudication[5].category.coding[0].code #noncovered
item[1].adjudication[5].category.coding[0].display "Noncovered"
item[1].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[1].adjudication[5].amount.value 0.0
item[1].adjudication[5].amount.currency #USD
item[2].sequence 3
item[2].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[2].revenue.coding[0].code #0305
item[2].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[2].productOrService.coding[0].code #99231
item[2].servicedPeriod.start "2017-05-23"
item[2].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[2].locationCodeableConcept.coding[0].code #21
item[2].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[2].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[0].category.coding[0].code #submitted
item[2].adjudication[0].category.coding[0].display "Submitted Amount"
item[2].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[2].adjudication[0].amount.value 104.2
item[2].adjudication[0].amount.currency #USD
item[2].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[1].category.coding[0].code #copay
item[2].adjudication[1].category.coding[0].display "CoPay"
item[2].adjudication[1].category.text "Patient Co-Payment"
item[2].adjudication[1].amount.value 0.0
item[2].adjudication[1].amount.currency #USD
item[2].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[2].category.coding[0].code #eligible
item[2].adjudication[2].category.coding[0].display "Eligible Amount"
item[2].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[2].adjudication[2].amount.value 0.0
item[2].adjudication[2].amount.currency #USD
item[2].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[3].category.coding[0].code #deductible
item[2].adjudication[3].category.coding[0].display "Deductible"
item[2].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[2].adjudication[3].amount.value 0.0
item[2].adjudication[3].amount.currency #USD
item[2].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[2].adjudication[4].category.coding[0].code #benefit
item[2].adjudication[4].category.coding[0].display "Benefit Amount"
item[2].adjudication[4].category.text "Amount payable under the coverage"
item[2].adjudication[4].amount.value 0.0
item[2].adjudication[4].amount.currency #USD
item[2].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[2].adjudication[5].category.coding[0].code #noncovered
item[2].adjudication[5].category.coding[0].display "Noncovered"
item[2].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[2].adjudication[5].amount.value 0.0
item[2].adjudication[5].amount.currency #USD
item[3].sequence 4
item[3].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[3].revenue.coding[0].code #0324
item[3].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[3].productOrService.coding[0].code #99231
item[3].servicedPeriod.start "2017-05-23"
item[3].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[3].locationCodeableConcept.coding[0].code #21
item[3].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[3].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[0].category.coding[0].code #submitted
item[3].adjudication[0].category.coding[0].display "Submitted Amount"
item[3].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[3].adjudication[0].amount.value 171.6
item[3].adjudication[0].amount.currency #USD
item[3].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[1].category.coding[0].code #copay
item[3].adjudication[1].category.coding[0].display "CoPay"
item[3].adjudication[1].category.text "Patient Co-Payment"
item[3].adjudication[1].amount.value 0.0
item[3].adjudication[1].amount.currency #USD
item[3].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[2].category.coding[0].code #eligible
item[3].adjudication[2].category.coding[0].display "Eligible Amount"
item[3].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[3].adjudication[2].amount.value 0.0
item[3].adjudication[2].amount.currency #USD
item[3].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[3].category.coding[0].code #deductible
item[3].adjudication[3].category.coding[0].display "Deductible"
item[3].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[3].adjudication[3].amount.value 0.0
item[3].adjudication[3].amount.currency #USD
item[3].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[3].adjudication[4].category.coding[0].code #benefit
item[3].adjudication[4].category.coding[0].display "Benefit Amount"
item[3].adjudication[4].category.text "Amount payable under the coverage"
item[3].adjudication[4].amount.value 0.0
item[3].adjudication[4].amount.currency #USD
item[3].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[3].adjudication[5].category.coding[0].code #noncovered
item[3].adjudication[5].category.coding[0].display "Noncovered"
item[3].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[3].adjudication[5].amount.value 0.0
item[3].adjudication[5].amount.currency #USD
item[4].sequence 5
item[4].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[4].revenue.coding[0].code #0259
item[4].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[4].productOrService.coding[0].code #99231
item[4].servicedPeriod.start "2017-05-23"
item[4].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[4].locationCodeableConcept.coding[0].code #21
item[4].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[4].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[0].category.coding[0].code #submitted
item[4].adjudication[0].category.coding[0].display "Submitted Amount"
item[4].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[4].adjudication[0].amount.value 381.8
item[4].adjudication[0].amount.currency #USD
item[4].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[1].category.coding[0].code #copay
item[4].adjudication[1].category.coding[0].display "CoPay"
item[4].adjudication[1].category.text "Patient Co-Payment"
item[4].adjudication[1].amount.value 0.0
item[4].adjudication[1].amount.currency #USD
item[4].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[2].category.coding[0].code #eligible
item[4].adjudication[2].category.coding[0].display "Eligible Amount"
item[4].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[4].adjudication[2].amount.value 0.0
item[4].adjudication[2].amount.currency #USD
item[4].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[3].category.coding[0].code #deductible
item[4].adjudication[3].category.coding[0].display "Deductible"
item[4].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[4].adjudication[3].amount.value 0.0
item[4].adjudication[3].amount.currency #USD
item[4].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[4].adjudication[4].category.coding[0].code #benefit
item[4].adjudication[4].category.coding[0].display "Benefit Amount"
item[4].adjudication[4].category.text "Amount payable under the coverage"
item[4].adjudication[4].amount.value 0.0
item[4].adjudication[4].amount.currency #USD
item[4].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[4].adjudication[5].category.coding[0].code #noncovered
item[4].adjudication[5].category.coding[0].display "Noncovered"
item[4].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[4].adjudication[5].amount.value 0.0
item[4].adjudication[5].amount.currency #USD
item[5].sequence 6
item[5].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[5].revenue.coding[0].code #0250
item[5].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[5].productOrService.coding[0].code #99231
item[5].servicedPeriod.start "2017-05-23"
item[5].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[5].locationCodeableConcept.coding[0].code #21
item[5].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[5].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[0].category.coding[0].code #submitted
item[5].adjudication[0].category.coding[0].display "Submitted Amount"
item[5].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[5].adjudication[0].amount.value 54.2
item[5].adjudication[0].amount.currency #USD
item[5].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[1].category.coding[0].code #copay
item[5].adjudication[1].category.coding[0].display "CoPay"
item[5].adjudication[1].category.text "Patient Co-Payment"
item[5].adjudication[1].amount.value 0.0
item[5].adjudication[1].amount.currency #USD
item[5].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[2].category.coding[0].code #eligible
item[5].adjudication[2].category.coding[0].display "Eligible Amount"
item[5].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[5].adjudication[2].amount.value 0.0
item[5].adjudication[2].amount.currency #USD
item[5].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[3].category.coding[0].code #deductible
item[5].adjudication[3].category.coding[0].display "Deductible"
item[5].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[5].adjudication[3].amount.value 0.0
item[5].adjudication[3].amount.currency #USD
item[5].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[5].adjudication[4].category.coding[0].code #benefit
item[5].adjudication[4].category.coding[0].display "Benefit Amount"
item[5].adjudication[4].category.text "Amount payable under the coverage"
item[5].adjudication[4].amount.value 0.0
item[5].adjudication[4].amount.currency #USD
item[5].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[5].adjudication[5].category.coding[0].code #noncovered
item[5].adjudication[5].category.coding[0].display "Noncovered"
item[5].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[5].adjudication[5].amount.value 0.0
item[5].adjudication[5].amount.currency #USD
item[6].sequence 7
item[6].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[6].revenue.coding[0].code #0710
item[6].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[6].productOrService.coding[0].code #99231
item[6].servicedPeriod.start "2017-05-23"
item[6].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[6].locationCodeableConcept.coding[0].code #21
item[6].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[6].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[6].adjudication[0].category.coding[0].code #submitted
item[6].adjudication[0].category.coding[0].display "Submitted Amount"
item[6].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[6].adjudication[0].amount.value 642.8
item[6].adjudication[0].amount.currency #USD
item[6].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[6].adjudication[1].category.coding[0].code #copay
item[6].adjudication[1].category.coding[0].display "CoPay"
item[6].adjudication[1].category.text "Patient Co-Payment"
item[6].adjudication[1].amount.value 0.0
item[6].adjudication[1].amount.currency #USD
item[6].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[6].adjudication[2].category.coding[0].code #eligible
item[6].adjudication[2].category.coding[0].display "Eligible Amount"
item[6].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[6].adjudication[2].amount.value 0.0
item[6].adjudication[2].amount.currency #USD
item[6].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[6].adjudication[3].category.coding[0].code #deductible
item[6].adjudication[3].category.coding[0].display "Deductible"
item[6].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[6].adjudication[3].amount.value 0.0
item[6].adjudication[3].amount.currency #USD
item[6].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[6].adjudication[4].category.coding[0].code #benefit
item[6].adjudication[4].category.coding[0].display "Benefit Amount"
item[6].adjudication[4].category.text "Amount payable under the coverage"
item[6].adjudication[4].amount.value 0.0
item[6].adjudication[4].amount.currency #USD
item[6].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[6].adjudication[5].category.coding[0].code #noncovered
item[6].adjudication[5].category.coding[0].display "Noncovered"
item[6].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[6].adjudication[5].amount.value 0.0
item[6].adjudication[5].amount.currency #USD
item[7].sequence 8
item[7].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[7].revenue.coding[0].code #0210
item[7].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[7].productOrService.coding[0].code #99231
item[7].servicedPeriod.start "2017-05-23"
item[7].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[7].locationCodeableConcept.coding[0].code #21
item[7].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[7].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[7].adjudication[0].category.coding[0].code #submitted
item[7].adjudication[0].category.coding[0].display "Submitted Amount"
item[7].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[7].adjudication[0].amount.value 1258.0
item[7].adjudication[0].amount.currency #USD
item[7].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[7].adjudication[1].category.coding[0].code #copay
item[7].adjudication[1].category.coding[0].display "CoPay"
item[7].adjudication[1].category.text "Patient Co-Payment"
item[7].adjudication[1].amount.value 120.0
item[7].adjudication[1].amount.currency #USD
item[7].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[7].adjudication[2].category.coding[0].code #eligible
item[7].adjudication[2].category.coding[0].display "Eligible Amount"
item[7].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[7].adjudication[2].amount.value 1542.01
item[7].adjudication[2].amount.currency #USD
item[7].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[7].adjudication[3].category.coding[0].code #deductible
item[7].adjudication[3].category.coding[0].display "Deductible"
item[7].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[7].adjudication[3].amount.value 0.0
item[7].adjudication[3].amount.currency #USD
item[7].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[7].adjudication[4].category.coding[0].code #benefit
item[7].adjudication[4].category.coding[0].display "Benefit Amount"
item[7].adjudication[4].category.text "Amount payable under the coverage"
item[7].adjudication[4].amount.value 1393.57
item[7].adjudication[4].amount.currency #USD
item[7].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[7].adjudication[5].category.coding[0].code #noncovered
item[7].adjudication[5].category.coding[0].display "Noncovered"
item[7].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[7].adjudication[5].amount.value 0.0
item[7].adjudication[5].amount.currency #USD
item[8].sequence 9
item[8].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[8].revenue.coding[0].code #0272
item[8].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[8].productOrService.coding[0].code #99231
item[8].servicedPeriod.start "2017-05-23"
item[8].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[8].locationCodeableConcept.coding[0].code #21
item[8].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[8].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[8].adjudication[0].category.coding[0].code #submitted
item[8].adjudication[0].category.coding[0].display "Submitted Amount"
item[8].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[8].adjudication[0].amount.value 303.4
item[8].adjudication[0].amount.currency #USD
item[8].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[8].adjudication[1].category.coding[0].code #copay
item[8].adjudication[1].category.coding[0].display "CoPay"
item[8].adjudication[1].category.text "Patient Co-Payment"
item[8].adjudication[1].amount.value 0.0
item[8].adjudication[1].amount.currency #USD
item[8].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[8].adjudication[2].category.coding[0].code #eligible
item[8].adjudication[2].category.coding[0].display "Eligible Amount"
item[8].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[8].adjudication[2].amount.value 0.0
item[8].adjudication[2].amount.currency #USD
item[8].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[8].adjudication[3].category.coding[0].code #deductible
item[8].adjudication[3].category.coding[0].display "Deductible"
item[8].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[8].adjudication[3].amount.value 0.0
item[8].adjudication[3].amount.currency #USD
item[8].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[8].adjudication[4].category.coding[0].code #benefit
item[8].adjudication[4].category.coding[0].display "Benefit Amount"
item[8].adjudication[4].category.text "Amount payable under the coverage"
item[8].adjudication[4].amount.value 0.0
item[8].adjudication[4].amount.currency #USD
item[8].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[8].adjudication[5].category.coding[0].code #noncovered
item[8].adjudication[5].category.coding[0].display "Noncovered"
item[8].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[8].adjudication[5].amount.value 0.0
item[8].adjudication[5].amount.currency #USD
item[9].sequence 10
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item[9].revenue.coding[0].code #0370
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item[9].productOrService.coding[0].code #99231
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item[9].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[9].locationCodeableConcept.coding[0].code #21
item[9].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[9].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[9].adjudication[0].category.coding[0].code #submitted
item[9].adjudication[0].category.coding[0].display "Submitted Amount"
item[9].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[9].adjudication[0].amount.value 222.8
item[9].adjudication[0].amount.currency #USD
item[9].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[9].adjudication[1].category.coding[0].code #copay
item[9].adjudication[1].category.coding[0].display "CoPay"
item[9].adjudication[1].category.text "Patient Co-Payment"
item[9].adjudication[1].amount.value 0.0
item[9].adjudication[1].amount.currency #USD
item[9].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[9].adjudication[2].category.coding[0].code #eligible
item[9].adjudication[2].category.coding[0].display "Eligible Amount"
item[9].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[9].adjudication[2].amount.value 0.0
item[9].adjudication[2].amount.currency #USD
item[9].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[9].adjudication[3].category.coding[0].code #deductible
item[9].adjudication[3].category.coding[0].display "Deductible"
item[9].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[9].adjudication[3].amount.value 0.0
item[9].adjudication[3].amount.currency #USD
item[9].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[9].adjudication[4].category.coding[0].code #benefit
item[9].adjudication[4].category.coding[0].display "Benefit Amount"
item[9].adjudication[4].category.text "Amount payable under the coverage"
item[9].adjudication[4].amount.value 0.0
item[9].adjudication[4].amount.currency #USD
item[9].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[9].adjudication[5].category.coding[0].code #noncovered
item[9].adjudication[5].category.coding[0].display "Noncovered"
item[9].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[9].adjudication[5].amount.value 0.0
item[9].adjudication[5].amount.currency #USD
item[10].sequence 11
item[10].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[10].revenue.coding[0].code #0730
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item[10].productOrService.coding[0].code #99231
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item[10].locationCodeableConcept.coding[0].code #21
item[10].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[10].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[10].adjudication[0].category.coding[0].code #submitted
item[10].adjudication[0].category.coding[0].display "Submitted Amount"
item[10].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[10].adjudication[0].amount.value 33.9
item[10].adjudication[0].amount.currency #USD
item[10].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[10].adjudication[1].category.coding[0].code #copay
item[10].adjudication[1].category.coding[0].display "CoPay"
item[10].adjudication[1].category.text "Patient Co-Payment"
item[10].adjudication[1].amount.value 0.0
item[10].adjudication[1].amount.currency #USD
item[10].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[10].adjudication[2].category.coding[0].code #eligible
item[10].adjudication[2].category.coding[0].display "Eligible Amount"
item[10].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[10].adjudication[2].amount.value 0.0
item[10].adjudication[2].amount.currency #USD
item[10].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[10].adjudication[3].category.coding[0].code #deductible
item[10].adjudication[3].category.coding[0].display "Deductible"
item[10].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[10].adjudication[3].amount.value 0.0
item[10].adjudication[3].amount.currency #USD
item[10].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[10].adjudication[4].category.coding[0].code #benefit
item[10].adjudication[4].category.coding[0].display "Benefit Amount"
item[10].adjudication[4].category.text "Amount payable under the coverage"
item[10].adjudication[4].amount.value 0.0
item[10].adjudication[4].amount.currency #USD
item[10].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[10].adjudication[5].category.coding[0].code #noncovered
item[10].adjudication[5].category.coding[0].display "Noncovered"
item[10].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[10].adjudication[5].amount.value 0.0
item[10].adjudication[5].amount.currency #USD
item[11].sequence 12
item[11].revenue.coding[0].system "http://www.nubc.org/RevenueCodes"
item[11].revenue.coding[0].code #0450
item[11].productOrService.coding[0].system "http://www.ama-assn.org/go/cpt"
item[11].productOrService.coding[0].code #99231
item[11].servicedPeriod.start "2017-05-23"
item[11].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[11].locationCodeableConcept.coding[0].code #21
item[11].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[11].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[11].adjudication[0].category.coding[0].code #submitted
item[11].adjudication[0].category.coding[0].display "Submitted Amount"
item[11].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[11].adjudication[0].amount.value 592.4
item[11].adjudication[0].amount.currency #USD
item[11].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[11].adjudication[1].category.coding[0].code #copay
item[11].adjudication[1].category.coding[0].display "CoPay"
item[11].adjudication[1].category.text "Patient Co-Payment"
item[11].adjudication[1].amount.value 0.0
item[11].adjudication[1].amount.currency #USD
item[11].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[11].adjudication[2].category.coding[0].code #eligible
item[11].adjudication[2].category.coding[0].display "Eligible Amount"
item[11].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[11].adjudication[2].amount.value 0.0
item[11].adjudication[2].amount.currency #USD
item[11].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[11].adjudication[3].category.coding[0].code #deductible
item[11].adjudication[3].category.coding[0].display "Deductible"
item[11].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[11].adjudication[3].amount.value 0.0
item[11].adjudication[3].amount.currency #USD
item[11].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[11].adjudication[4].category.coding[0].code #benefit
item[11].adjudication[4].category.coding[0].display "Benefit Amount"
item[11].adjudication[4].category.text "Amount payable under the coverage"
item[11].adjudication[4].amount.value 0.0
item[11].adjudication[4].amount.currency #USD
item[11].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[11].adjudication[5].category.coding[0].code #noncovered
item[11].adjudication[5].category.coding[0].display "Noncovered"
item[11].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[11].adjudication[5].amount.value 0.0
item[11].adjudication[5].amount.currency #USD
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item[12].productOrService.coding[0].code #99231
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item[12].locationCodeableConcept.coding[0].system "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"
item[12].locationCodeableConcept.coding[0].code #21
item[12].locationCodeableConcept.text "HOSPITAL - INPATIENT HOSPITAL"
item[12].adjudication[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[12].adjudication[0].category.coding[0].code #submitted
item[12].adjudication[0].category.coding[0].display "Submitted Amount"
item[12].adjudication[0].category.text "The total submitted amount for the claim or group or line item."
item[12].adjudication[0].amount.value 2673.2
item[12].adjudication[0].amount.currency #USD
item[12].adjudication[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[12].adjudication[1].category.coding[0].code #copay
item[12].adjudication[1].category.coding[0].display "CoPay"
item[12].adjudication[1].category.text "Patient Co-Payment"
item[12].adjudication[1].amount.value 0.0
item[12].adjudication[1].amount.currency #USD
item[12].adjudication[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[12].adjudication[2].category.coding[0].code #eligible
item[12].adjudication[2].category.coding[0].display "Eligible Amount"
item[12].adjudication[2].category.text "Amount of the change which is considered for adjudication."
item[12].adjudication[2].amount.value 0.0
item[12].adjudication[2].amount.currency #USD
item[12].adjudication[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[12].adjudication[3].category.coding[0].code #deductible
item[12].adjudication[3].category.coding[0].display "Deductible"
item[12].adjudication[3].category.text "Amount deducted from the eligible amount prior to adjudication."
item[12].adjudication[3].amount.value 0.0
item[12].adjudication[3].amount.currency #USD
item[12].adjudication[4].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
item[12].adjudication[4].category.coding[0].code #benefit
item[12].adjudication[4].category.coding[0].display "Benefit Amount"
item[12].adjudication[4].category.text "Amount payable under the coverage"
item[12].adjudication[4].amount.value 0.0
item[12].adjudication[4].amount.currency #USD
item[12].adjudication[5].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
item[12].adjudication[5].category.coding[0].code #noncovered
item[12].adjudication[5].category.coding[0].display "Noncovered"
item[12].adjudication[5].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
item[12].adjudication[5].amount.value 0.0
item[12].adjudication[5].amount.currency #USD
adjudication[0].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
adjudication[0].category.coding[0].code #noncovered
adjudication[0].category.coding[0].display "Noncovered"
adjudication[0].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
adjudication[0].amount.value 0.0
adjudication[0].amount.currency #USD
total[0].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
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total[0].category.coding[0].display "Submitted Amount"
total[0].category.text "The total submitted amount for the claim or group or line item."
total[0].amount.value 7147.2
total[0].amount.currency #USD
total[1].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[1].category.coding[0].code #eligible
total[1].category.coding[0].display "Eligible Amount"
total[1].category.text "Amount of the change which is considered for adjudication."
total[1].amount.value 1542.01
total[1].amount.currency #USD
total[2].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[2].category.coding[0].code #deductible
total[2].category.coding[0].display "Deductible"
total[2].category.text "Amount deducted from the eligible amount prior to adjudication."
total[2].amount.value 0.0
total[2].amount.currency #USD
total[3].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[3].category.coding[0].code #copay
total[3].category.coding[0].display "CoPay"
total[3].category.text "Patient Co-Payment"
total[3].amount.value 120.0
total[3].amount.currency #USD
total[4].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[4].category.coding[0].code #noncovered
total[4].category.coding[0].display "Noncovered"
total[4].category.text "The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
total[4].amount.value 0.0
total[4].amount.currency #USD
total[5].category.coding[0].system "http://terminology.hl7.org/CodeSystem/adjudication"
total[5].category.coding[0].code #benefit
total[5].category.coding[0].display "Benefit Amount"
total[5].category.text "Amount payable under the coverage"
total[5].amount.value 1393.57
total[5].amount.currency #USD
total[6].category.coding[0].system "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
total[6].category.coding[0].code #memberliability
total[6].category.coding[0].display "Member liability"
total[6].category.text "The amount of the member's liability."
total[6].amount.value 0.0
total[6].amount.currency #USD